Paul Aridgides

PET Response-Guided Treatment of Hodgkin's Lymphoma: A Review of the Evidence and Active Clinical Trials

Risk-adaptive therapy for Hodgkins lymphoma focuses on treatment modifications based on assessment of response. [18F]Fluoro-deoxyglucose positron emission tomography (PET) performed during or after completion of chemotherapy is a strong prognostic factor for eventual treatment outcome. Conceptually, this strategy seeks to increase efficacy and minimize toxicity through the appropriate selection of patients for either therapy escalation (high-risk, PET positive) or de-escalation (low-risk, PET negative). Preliminary evidence with tailoring both chemotherapy (drug selection, number of cycles, and dose) and radiotherapy (omission or inclusion) is varied; however, numerous clinical trials seeking to validate this approach are ongoing. This paper summarizes the available evidence and active protocols involving PET response-adapted therapy for adult (early and advanced stages) Hodgkins lymphoma.

Radiotherapy for Stage III Non–Small-Cell Lung Carcinoma in the Elderly (Age ≥ 70 years)

BACKGROUND Elderly patients are underrepresented in trials that establish definitive chemoradiotherapy as the standard of care for inoperable stage III non-small-cell lung carcinoma (NSCLC). This study analyzed radiotherapy treatment delivery and outcomes at our institution according to elderly (≥ 70 years old) or younger (< 70 years) age. METHODS Records of patients who received radiotherapy for stage III NSCLC between January 1998 and February 2010 were reviewed. Factors analyzed included Eastern Cooperative Oncology Group Performance Status (ECOG PS), weight loss, radiation therapy intent, and chemotherapy administered. RESULTS A total of 189 patients with stage III NSCLC were analyzed (age range, 28-92 years). Elderly patients (n = 86) were more likely to have ECOG PS ≥ 2 (P < .05) and receive palliative treatment (P < .05). Elderly patients less often received concurrent chemoradiotherapy (P < .05) as well as cisplatin (P < .05). Median survival was 10.3 months for elderly patients compared with 17.2 months for younger patients (P < .05 ). In addition, elderly patients with ECOG PS (P < .05) as well as those who received definitive concurrent chemoradiotherapy (P < .05) had inferior outcomes compared with otherwise similar younger patients. However, on multivariate analysis, elderly age was not associated (P = .428) with increased risk of death, whereas poor ECOG PS (≥ 2) was significant (P < .05). In elderly patients, definitive treatment (P < .05), chemotherapy administration (P < .05), and ECOG PS of 0-1 (P < .05) were associated with improved outcome. CONCLUSIONS Although elderly patients with stage III NSCLC experience inferior outcomes than younger patients with comparable disease, they are also more likely to receive suboptimal therapy. On multivariate analysis, advanced age was not associated with worse survival, which indicates that appropriately selected elderly patients should receive definitive chemoradiotherapy.

Stereotactic Body Radiation Therapy for Stage I Non–Small Cell Lung Cancer

Stereotactic body radiation therapy (SBRT) has had a profound impact on the treatment paradigm for medically inoperable patients with stage I non-small cell lung cancer. Local control and survival outcomes from prospective collaborative trials using SBRT have been highly favorable in this challenging patient population. Further study in medically operable patients is ongoing; however, randomized trials to help answer this question have terminated early because of poor accrual. Available prospective and retrospective data are discussed for the use of SBRT with regard to the medically inoperable and operable patient populations, as well as considerations for fractionation, dose, and toxicity.

Atypical Teratoid/Rhabdoid Tumor (AT/RT)

Atypical Teratoid/Rhabdoid Tumor (AT/RT) is a rare and aggressive tumor of the Pediatric Central Nervous System (CNS) that was first described in 1987 (Biggs et al. 1987). Its aggressive behavior and predilection for infants who are less than 2 years of age enticed further study and pathological characterization over the 1990s (Burger et al. 1998; Rorke et al. 1996b). AT/RT histopathology is characterized by complex rhabdoid, epithelial, and mesenchymal cellular morphology and is genetically defined by loss of SMARCB1. Despite this early observation, AT/RT remains a challenging disease, with high mortality rates despite aggressive multimodality therapy including surgery, various chemotherapy regimens with or without stem cell transplant, intrathecal chemotherapy, and radiotherapy. The challenge is due in part to the very young age of presentation for most patients which can limit aggressive treatment particularly radiotherapy, as well as the relatively high rate of disseminated disease at diagnosis. Retrospective series, reported across multiple institutions, helped guide the development of a Children Oncology Group (COG) study designed for AT/RT (ACNS0333) that closed for accrual in February 2014. This was the first cooperative group prospective study dedicated for ATRT patients in an attempt to standardize the approach to treat AT/RT based on best available data from previous published experiences This chapter discusses the epidemiology of AT/RT, clinical features and evaluation, pathology and genetic abnormalities, and current treatment approaches. In addition, experimental therapies under investigation, as well as salvage treatment options, are reviewed.

PS01.50: Respiratory-Gated Stereotactic Body Radiation Therapy for Stage I Non–Small Cell Lung Cancer: A Retrospective Review: Topic: Radiation Oncology

Background: We previously reported that a discrete appearance and limited extent of mediastinal lymph nodes (MLNs) were associated with a better outcome of chemoradiotherapy (CRT) (Horinouchi et al., IJROBP 2016). The pretreatment diagnosis of MLNs is essential for appropriate patient selection. However, a substantial proportion of patient do not undergo invasive tissue sampling in daily clinical practice. Methods: Between 1997 and 2010, we analyzed consecutive patients diagnosed as having cIIIA-N2 NSCLC. The patient characteristics, information on the pretreatment pathological N2 diagnosis, progressionfree survival and overall survival were investigated. The appearance of MLNs was classified into two groups (discrete [D] or infiltrative [I]) according to the criteria introduced by the ACCP (Silvestri et al., Chest 2013). The extent of MLNs was divided into limited (closest to primary tumor) or extended (including upper MLNs for tumors in lower lobes and vice versa). Results: A total of 148 patients (118 men and 30 women; median age, 62 years) with cIIIA-N2 NSCLC received CRT during the study period. Invasive tissue sampling (pDx) and imaging diagnosis only (iDx) were used for the pretreatment diagnosis of N2 lymph nodes in 31 and 117 patients, respectively. In patients with pDx, the disease characteristics were as follows: appearance of MLNs (D/ I), 22/9; extent of MLNs (limited [L]/extended [E]), 19/12. In patients with an iDx, the disease characteristics were as follows: appearance of MLNs (D/ I), 63/54; extent of MLNs (L/E), 63/54. Subgroup survival analyses were summarized in the table.