P. Daroui

A novel paradigm in the treatment of oligometastatic non-small cell lung cancer

BACKGROUND Stage IV non-small cell lung cancer (NSCLC) is thought to uniformly carry a poor prognosis with a median survival of less than 1 year and 5-year survival of less than 5%. In patients with a low volume (i.e. single site) of distant disease, the prognosis is slightly more favorable than that of more advanced (i.e. multiple sites of metastases) disease. For those with limited metastases, we developed a paradigm of adding concurrent chemotherapy and radiotherapy to the primary tumor once the tumor demonstrated chemotherapy sensitivity. METHODS Charts of patients from 1999-2006 with non-small cell lung cancer were reviewed to find those with a single extra-thoracic site of disease treated with combined modality therapy. We found nine patients of 640 who met these criteria. Initial treatment consisted of induction chemotherapy, except for brain metastases which were managed first (n=1). If patients experienced a response to chemotherapy without new metastases, the extra-thoracic site was treated for total control with curative dose chemoradiotherapy to the primary site. Survival, time to progression, and sites of progression were assessed. RESULTS Median survival was 28 months (95% CI 18-50 mo) with median time to progression of 15 months (95% CI 8-24 mo). All except one patient progressed in the CNS, either with brain metastases (n=7) or leptomeningeal disease (n=1). CONCLUSIONS Such an approach offers the potential for enhanced quality and quantity of survival by incorporating aggressive RT for select patients without disease progression after induction chemotherapy. Patients tended to fail in the CNS, suggesting the importance of continued surveillance of the neuraxis or possibly prophylactic cranial irradiation. Future plans will correlate outcomes with molecular markers.

Practice Patterns in the Delivery of Radiation Therapy After Mastectomy Among the University of California Athena Breast Health Network

BACKGROUND Practice patterns vary with the planning and delivery of PMRT. In our investigation we examined practice patterns in the use of chest wall bolus and a boost among the Athena Breast Health Network (Athena). MATERIALS AND METHODS Athena is a collaboration among the 5 University of California Medical Centers that aims to integrate clinical care and research. From February 2011 to June 2011, all physicians specializing in the multidisciplinary treatment of breast cancer were invited to take a Web-based practice patterns survey. Sixty-two of the 239 questions focused on radiation therapy practice environment, decision-making processes, and treatment management, including the use of a bolus or boost in PMRT. RESULTS Ninety-two percent of the radiation oncologists specializing in breast cancer completed the survey. All of the responders use a material to increase the surface dose to the chest wall during PMRT. Materials used included brass mesh, commercial bolus, and custom-designed wax bolus. Fifty percent used tissue equivalent superflab bolus. Fifty-five percent of the respondents routinely use a boost to the chest wall in PMRT. Eighteen percent give a boost depending on the margin status, and 3 of 11 (27%) do not use a boost. CONCLUSION Our investigation documents practice pattern variation for the use of a PMRT boost and the use of chest wall bolus among the University of California breast cancer radiation oncologists. Further understanding of the practice pattern variation will help guide clinicians in our cancer centers to a more uniform approach in the delivery of PMRT.

Three-year outcomes of a once daily fractionation scheme for accelerated partial breast irradiation (APBI) using 3-D conformal radiotherapy (3D-CRT).

The aim of this study was to report 3‐year outcomes of toxicity, cosmesis, and local control using a once daily fractionation scheme (49.95 Gy in 3.33 Gy once daily fractions) for accelerated partial breast irradiation (APBI) using three‐dimensional conformal radiotherapy (3D‐CRT). Between July 2008 and August 2010, women aged ≥40 years with ductal carcinoma in situ or node‐negative invasive breast cancer ≤3 cm in diameter, treated with breast‐conserving surgery achieving negative margins, were accrued to a prospective study. Women were treated with APBI using 3–5 photon beams, delivering 49.95 Gy over 15 once daily fractions over 3 weeks. Patients were assessed for toxicities, cosmesis, and local control rates before APBI and at specified time points. Thirty‐four patients (mean age 60 years) with Tis 0 (n = 9) and T1N0 (n = 25) breast cancer were treated and followed up for an average of 39 months. Only 3% (1/34) patients experienced a grade 3 subcutaneous fibrosis and breast edema and 97% of the patients had good/excellent cosmetic outcome at 3 years. The 3‐year rate of ipsilateral breast tumor recurrence (IBTR) was 0% while the rate of contralateral breast events was 6%. The 3‐year disease‐free survival (DFS), overall survival (OS), and breast cancer‐specific survival (BCSS) was 94%, 100%, and 100%, respectively. Our novel accelerated partial breast fractionation scheme of 15 once daily fractions of 3.33 Gy (49.95 Gy total) is a remarkably well‐tolerated regimen of 3D‐CRT‐based APBI. A larger cohort of patients is needed to further ascertain the toxicity of this accelerated partial breast regimen.

Utilization of breast conserving therapy in stages 0, I, and II breast cancer patients in New Jersey: an American College of Surgeons National Cancer Data Base (NCDB) analysis.

BackgroundThe purpose of the study was to determine the use of breast conservation surgery (BCS) followed by whole breast irradiation [BCS+radiation therapy (RT)] in stages 0, I, and II breast cancer patients treated in New Jersey using the National Cancer Database. Materials and MethodsA retrospective analysis was conducted using the data from 13 hospitals in New Jersey certified by the American College of Surgeons Commission on Cancer and members of the Cancer Institute of New Jerseys Network affiliates. Subjects with a first primary malignancy of the breast (stages 0, I, and II) treated from 2000 to 2006 were included in the analysis. ResultsA total of 11,146 patients with stage 0 (n=2843), stage I (n=4757), and stage II (n=3546) were treated for their breast cancer. Of stage 0, I, and II patients, 72% (n=2053), 73% (n=3482), and 53% (n=1865) received BCS, respectively. Of these patients, 40% (n=826), 67.6% (n=2353), and 63% (n=1177) received adjuvant RT after BCS for their stages 0, I, and II, respectively. Use of BCS+RT was equivalent across racial groups and all ages, except patients above 70 years of age (61% <40 y, 57% 40 to 49 y, 60% 50 to 59 y, 65% 60 to 69 y, and 51% >70 y). ConclusionsThese data report an underutilization of RT after BCS in patients with stage 0 breast cancer treated across 13 hospitals in New Jersey. The Commission on Cancers Rapid Quality Reporting System may be one method of identifying groups of patients not receiving care according to evidence-based guidelines.

The dosimetric impact of image guided radiation therapy by intratumoral fiducial markers

PURPOSE Pancreatic fiducials have proven superior over other isocenter localization surrogates, including anatomical landmarks and intratumoral or adjacent stents. The more clinically relevant dosimetric impact of image guided radiation therapy (IGRT) using intratumoral fiducial markers versus bony anatomy has not yet been described and is therefore the focus of the current study. METHODS AND MATERIALS Using daily orthogonal kV or cone beam computed tomography (CBCT) images and positional and dosimetric data were analyzed for 12 consecutive patients treated with fiducial based IGRT and volumetric modulated arc therapy to the intact pancreas. The shifts from fiducial to bone (ΔFid-Bone) required to realign the daily fiducial-matched pretreatment images (kV, CBCTs) to the planning computed tomography (CT) using bony anatomic landmarks were recorded. The isocenter was then shifted by (ΔFid-Bone) for 5 evenly spaced treatments, and the dosimetric impact of ΔFid-Bone was calculated for planning target volume coverage (PTV50.4 and PTV47.9) and organs at risk (liver, kidney, and stomach/duodenum). RESULTS The ΔFid-Bone were greatest in the superoinferior direction (ΔFid-Bone anteroposterior, 2.7 ± 3.0; left-right, 2.8 ± 2.8; superoinferior, 6.3 ± 7.9 mm; mean ± standard deviation; P = .03). PTV50.4 coverage was reduced by 13% (fiducial plan 95 ± 2.0 vs bone plan 82 ± 12%; P = .005; range, 5%-52%; >5% loss in all; and >10% loss in 42% of patients), and to a lesser degree for PTV47.9 (difference, -8%; range, 1%-30%; fiducial plan 100 ± 0.3% vs bone plan 92 ± 7.6%; P = .003; with reductions of >5% in 66% and >10% in 33% of patients). The dosimetric impact of ΔFid-Bone on the organs at risk was not significant. Positional shifts for kV- and CBCT-based realignments were nearly identical. CONCLUSION Compared with matching by fiducial markers, IGRT matched by bony anatomy substantially reduces the PTV50.4 and PTV47.9 coverage, supporting the use of intratumoral pancreatic markers for improved targeting in IGRT for pancreatic cancer.

Radiation dermatitis caused by a bolus effect from an abdominal compression device.

American Association of Physicists in Medicine (AAPM) Task Group 176 evaluated the dosimetric effects caused by couch tops and immobilization devices. The report analyzed the extensive physics-based literature on couch tops, stereotactic body radiation therapy (SBRT) frames, and body immobilization bags, while noting the scarcity of clinical reports of skin toxicity because of external devices. Here, we present a clinical case report of grade 1 abdominal skin toxicity owing to an abdominal compression device. We discuss the dosimetric implications of the utilized treatment plan as well as post hoc alternative plans and quantify differences in attenuation and skin dose/build-up between the device, a lower-density alternative device, and an open field. The description of the case includes a 66-year-old male with HER2 amplified poorly differentiated distal esophageal adenocarcinoma treated with neoadjuvant chemo-radiation and the use of an abdominal compression device. Radiation was delivered using volumetric modulated arc therapy (VMAT) with 2 arcs using abdominal compression and image guidance. The total dose was 50.4Gy delivered over 40 elapsed days. With 2 fractions remaining, the patient developed dermatitis in the area of the compression device. The original treatment plan did not include a contour of the device. Alternative post hoc treatment plans were generated, one to contour the device and a second with anterior avoidance. In conclusion, replanning with the device contoured revealed the bolus effect. The skin dose increased from 27 to 36Gy. planned target volume (PTV) coverage at 45Gy was reduced to 76.5% from 95.8%. The second VMAT treatment plan with an anterior avoidance sector and more oblique beam angles maintained PTV coverage and spared the anterior wall, however at the expense of substantially increased dose to lung. This case report provides an important reminder of the bolus effect from external devices such as abdominal compression. Special consideration must be given to contour and/or avoiding beam entrance to the device, and to the use of such devices in patients who may have heightened radiosensitivity, such as those who are human immunodeficiency virus (HIV)-positive.

Response to Letter to the Editor: Regarding “The dosimetric impact of image guided radiation therapy by intratumoral fiducial markers”

We thank the authors of the letter for their interest in our work.1 They make an interesting suggestion. The intention of the clinical prescription is to deliver to the planning target volume (PTV) the clinically required dose. This approach guarantees that the clinical target volume, which is inherently difficult to define accurately,2 receives the prescribed dose as required for appropriate clinical management throughout treatment. As indicated in our work, and also acknowledged in the letter, PTVs were generated by expanding internal target volumes (ITVs) by 5mm in all directions to account for setup uncertainties. Ideally, with accurate image guidance for each treatment and fiducial marker alignment, 5 mm would provide a sufficient margin for ITVs to be covered by the prescribed dose, with consideration of uncertainties throughout treatment. However, our findings indicate that without the use of fiducial markers, PTV margins would have to be 27 mm in superior inferior (SI), 9 mm in anterior posterior (AP), and 8mm in left right (LR), respectively, to account for 95% interfractional patient position variations. This magnitude is much greater than the intended 5 mm expansion with an appropriate image-guided radiation therapy technique. Therefore, inadequate coverage to the ITV is expected when bony anatomy is used for online matching. To obtain more quantitative data, we reanalyzed our data for ITV coverage (V100%). Our findings indicate that the novel method utilizing mean absolute shifts of all fractions (Bone PlanEST) was equivalent to dose summation for all fractions for which we extracted data on ITV

Recurrent squamous cell carcinoma involving cranial nerves in a patient with left glottic carcinoma treated with definitive radiation therapy: A case report

Practical Radiation Oncology (2017) 7, 100-102 www.practicalradonc.org Teaching Case Recurrent squamous cell carcinoma involving cranial nerves in a patient with left glottic carcinoma treated with definitive radiation therapy: A case report Kunal Sindhu BA a , William Armstrong MD b , Anton Hasso MD c , Ted Farzaneh MD d , Parima Daroui MD, PhD e, ⁎ a Warren Alpert School of Medicine, Brown University, Providence, Rhode Island Department of Otolaryngology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California c Department of Radiology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California d Department of Pathology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California e Department of Radiation Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California b Received 19 September 2016; revised 4 November 2016; accepted 10 November 2016 Introduction Side effects from definitive radiation therapy in patients with cancers of the head and neck are not uncommon. Controlling the acute side effects of treatment, including mucositis, xerostomia, dysphagia, and dysphonia, is of the utmost necessity because these symptoms are potentially debilitating and may jeopardize patients’ adherence to treatment regimens. In the longer term, persistent xeros- tomia, difficulties with speech and swallowing, and fibrosis have been noted in patients who have received radiation therapy. 1 Radiation-induced cranial neuritis, although rare, has also been observed and most often affects the sixth and twelfth cranial nerves. 2 When patients with a history of head or neck radiation treatment develop these symptoms, however, clinicians must maintain a wide differential diagnosis because each of these symptoms has a vast array of potential etiologies. In this report, we present a patient whose symptoms, although mirroring Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, University of California Irvine, 101 The City Drive South, Building 23, Orange, CA 92868. E-mail address: pdaroui@uci.edu (P. Daroui). some of those known to be long-term consequences of radiation therapy, were instead found to be a manifestation of a recurrence of squamous cell carcinoma (SCC) limited to the cranial nerve tract. Case report A 53-year-old man with a 50 pack-year smoking history initially presented to his primary care physician with nasal congestion and otalgia. Two months later, after antibiotics failed to ameliorate these symptoms, he developed progressive hoarseness and throat discomfort. Flexible fiberoptic laryngoscopy (FFL) performed by a specialist revealed an exophytic, left true vocal cord lesion. The patient was then referred to our institution, where a repeat FFL showed mucosal irregularity of the left true vocal cord in the context of otherwise symmetrically mobile vocal cords. Computed tomography scans of the neck demonstrated irregularity and thickening of the left true vocal cord with obscuration of the laryngeal ventricle. Microdirect laryngoscopy with partial excision of the left true vocal cord mass was performed to acquire tissue. A 10-mm mass along the superior surface of the left true http://dx.doi.org/10.1016/j.prro.2016.11.004 1879-8500/© 2016 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.