Ryan Rhome

Linear accelerator-based flattening-filter-free stereotactic radiosurgery for trigeminal neuralgia: Feasibility and patient-reported outcomes.

PURPOSE The purpose of this study was to assess the safety and outcomes of the clinical use of LINAC (linear accelerator)-based flattening-filter-free beams for delivering ablative stereotactic radiosurgery (SRS) for trigeminal neuralgia (TN). METHODS AND MATERIALS Thirty-six consecutive patients (34 unique patients) followed up by a single neurosurgeon and diagnosed with medically refractory unilateral TN were treated with SRS. There were 14 left-sided cases (41%) and 20 right-sided cases (59%). Twenty-eight of the patients (82%) had type 1 TN, and 6 (18%) had type 2 TN. Previous treatments were as follows: 10 patients (29%) had SRS to the ipsilateral TN (8 with Gamma Knife, 2 with LINAC), 4 (12%) had percutaneous rhizotomy, and 3 (9%) had microvascular decompression. A median prescription dose of 75 Gy (range, 70-80 Gy), prescribed to the 100% isodose line, was delivered in a single fraction. Before treatment delivery, image guidance verified stereotactic frame placement, head position, and final isocenter. The volume of brainstem receiving ≥10 Gy was <0.5 cm(3). At each visit, patients prospectively reported outcomes using the Barrow Neurological Institute (BNI) pain scale. RESULTS With a median follow-up of 3.1 months (range, 0.6-24.3; mean, 5.5 months), no patient experienced grade 1+ toxicities. There were no new episodes of dysesthesia, hypoesthesia, or long-term complications related to SRS. Median baseline (pre-SRS) BNI score was 5.0 (mean, 4.7). Clinical assessment at first follow-up (median, 1 month) demonstrated a median BNI score of 3.0 (mean, 3.1). When stratified by TN subtype, both type 1 and type 2 TN patients had a median BNI score of 3.0 at first follow-up. Thirty patients (88.2%) achieved a reduction in their BNI at their first follow-up, and 5 patients (15%) achieved a score <3, which represents medication-free pain relief. The median BNI at second follow-up (average, 6.3 months) was 2.5. CONCLUSIONS We report our experience with modern LINAC-based SRS using flattening-filter-free beams for TN. This treatment appears to be a safe and effective technique, although longer follow-up is needed to confirm durability. This modality may prove to be a viable treatment alternative for TN.

Postmastectomy Radiation in Breast Cancer Patients With Pathologically Positive Lymph Nodes After Neoadjuvant Chemotherapy: Usage Rates and Survival Trends

PURPOSE To analyze postmastectomy radiation therapy (PMRT) usage and its association with overall survival (OS) in breast cancer patients with pathologically positive lymph nodes after neoadjuvant chemotherapy (NAC). METHODS AND MATERIALS Using the National Cancer Database, we identified women with nonmetastatic breast cancer diagnosed from 2004 to 2013 who had received NAC and undergone mastectomy with macroscopic pathologically positive lymph nodes. Joinpoint regression models were used to assess temporal trends in annual PMRT usage. Multivariable regression models were used to identify factors associated with PMRT use. A time-dependent Cox model was used to evaluate the predictors of mortality. RESULTS The study included 29,270 patients, of whom 62.5% received PMRT. PMRT was markedly underused among all nodal subgroups, in particular, among ypN2 (68.4%) and ypN3 (67.0%) patients. Hispanic patients and those with Medicaid or Medicare insurance were less likely to receive PMRT than were non-Hispanics and patients with other insurance carriers. The adjusted 5-year OS rates were similar in ypN1 and ypN2 patients with or without PMRT but were significantly greater in ypN3 patients receiving PMRT (66% vs 63%; P=.042). On multivariable analysis, PMRT was associated with improved survival only among ypN3 patients after adjusting for patient, facility, and tumor variables (multivariable hazard ratio 0.85; 95% confidence interval 0.74-0.97). CONCLUSIONS A considerable portion of breast cancer patients with advanced residual nodal disease after NAC did not receive appropriate adjuvant radiation. We also found socioeconomic disparities in national PMRT practice patterns. Patients with ypN3 disease might derive a survival benefit from PMRT.

Adjuvant radiation for salivary gland malignancies is associated with improved survival: A National Cancer Database analysis

Objective There are no randomized data to support the use of postoperative radiation for salivary gland malignancies. This study uses the National Cancer Database (NCDB) to describe the epidemiology of salivary gland cancer patients and to investigate whether treatment with adjuvant radiation improves overall survival. Methods and materials A total of 8243 patients diagnosed with a major salivary gland cancer were identified from the NCDB. All patients received primary surgical resection of their malignancy. Patients were risk-stratified by adverse features, and overall survival rates were determined. Patients were considered high risk if they had extracapsular extension and/or positive margin after resection. Patients were considered intermediate risk if they did not meet the criteria for high risk but had pT3-T4 disease, pN+ disease, lymphovascular space invasion, adenoid cystic histology, or grade 2-3 disease. Patients who did not meet criteria for high or intermediate risk were considered low risk. Overall patient demographics, disease characteristics, treatment factors, and outcomes were summarized with descriptive statistics and analyzed with STATA. Results Median follow-up in this cohort was 42.4 months, with the median age of 58 years. Patients in the high-risk group had greater survival (hazard ratio [HR], 0.76; P = .002; 95% confidence interval [CI], 0.64-0.91) if they received adjuvant radiation therapy. In contrast, patients in the intermediate- (HR, 1.01; P = .904; 95% CI, 0.85-1.20) and low-risk groups (HR, 0.85; P = .427; 95% CI, 0.57-1.26) did not experience a survival benefit with adjuvant radiation therapy. Conclusions This large analysis compared survival outcomes between observation and adjuvant radiation alone in risk-stratified patients after resection of major salivary glands using a national database. The use of adjuvant radiation for high-risk major salivary gland cancers appears to offer a survival benefit. Although an overall survival benefit was not seen in low- and intermediate-risk salivary gland cancers, this study could not address impact on local control because of the limitations of the NCDB.