Shaakir Hasan

Hepatocellular carcinoma with child Pugh-A Cirrhosis treated with stereotactic body radiotherapy

AIM To evaluate the control, survival, and hepatic function for Child Pugh (CP)-A patients after Stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC). METHODS From 2009 to 2016, 40 patients with Barcelona Liver Clinic (BCLC) stages 0-B HCC and CP-A cirrhosis completed liver SBRT. The mean prescription dose was 45 Gy (40 to 50 Gy in 4-5 fractions). Local relapse, defined as recurrence within the planning target volume was assessed with intravenous multiphase contrast computed tomography or magnetic resonance imaging every 4-6 mo after completion of SBRT. Progression of cirrhosis was evaluated by CP and Model for End Stage Liver Disease scores every 3-4 mo. Toxicities were graded per the Common Terminology Criteria for Adverse Events (v4.03). Median follow-up was 24 mo. RESULTS Forty-nine HCC lesions among 40 patients were analyzed in this IRB approved retrospective study. Median tumor diameter was 3.5 cm (1.5-8.9 cm). Six patients with tumors ≥ 5 cm completed planned selected transarterial chemoembolization (TACE) in combination with SBRT. Eight patients underwent orthotropic live transplant (OLT) with SBRT as a bridging treatment (median time to transplant was 12 mo, range 5 to 23 mo). The Pathologic complete response (PCR) rate in this group was 62.5%. The 2-year in-field local control was 98% (1 failure). Intrahepatic control was 82% and 62% at 1 and 2 years, respectively. Overall survival (OS) was 92% and 60% at 1 and 2 years, with a median survival of 41 mo per Kaplan Meier analysis. At 1 and 2 years, 71% and 61% of patients retained CPA status. Of the patients with intrahepatic failures, 58% developed progressive cirrhosis, compared to 27% with controlled disease (P = 0.06). Survival specific to hepatic failure was 92%, 81%, and 69% at 12, 18, and 24 mo. There was no grade 3 or higher toxicity. On univariate analysis, gross tumor volume (GTV) < 23 cc was associated with freedom from CP progression (P = 0.05), hepatic failure-specific survival (P = 0.02), and trended with OS (P = 0.10). CONCLUSION SBRT is safe and effective in HCC with early cirrhosis and may extend waiting time for transplant in patients who may not otherwise be immediate candidates.

Determining the impact of pre-radiation treatment verification simulation/dry run by analyzing intradepartmental reported incidents and surveying staff and patients

PURPOSE Error identification in radiation therapy is critical to maintain a safe and efficient therapeutic environment. A verification simulation (VS; also called a dry run for patient information) provides a dedicated time prior to treatment to duplicate steps of patient setup, imaging, and treatment process as a final quality assurance step. Through the use of surveys and analysis of reported incidents, we sought to determine the value of a VS before initiating patient treatment. METHODS AND MATERIALS In November 2014, a VS was instituted across our network of 11 radiation oncology clinics. A comparison of the incident rate reported through our departmental incident learning system (ILS) was made between a non-VS group (965 patients who were treated in the 18 months prior to instituting the VS) and a VS group (984 patients who were treated over 18 months with the VS policy in place). From August to December 2016, surveys were completed by 211 patients and 55 physicians, nurses, and therapists detailing their perspectives on the VS. RESULTS There were 28 incidents (2.9%) in the non-VS group compared with 18 incidents (1.8%) in the VS group (P = .03). In the VS group, more incidents were detected before the day of treatment (P = .03) and fewer incidents on the day of treatment (P = .02). In addition, a trend toward fewer incidents after treatment started (P = .09) was observed. Patient surveys indicated that 99.5% of patients were informed of the VS, 83% reported decreased anxiety during treatment, and 5% indicated concerns about delaying treatment. The majority of staff members (67%) were satisfied with the VS. CONCLUSIONS A VS helps identify and correct incidents before the administration of radiation therapy and reduces patient anxiety.

Effect of intensity-modulated radiation therapy with SIB technique on local control and toxicity for neoadjuvant pelvic radiation with concurrent 5-fluorouracil based chemotherapy for rectal cancer compared with three-dimensional conformal radiation therapies.

632 Background: To compare the areas of residual disease after neoadjuvant pelvic radiation with 5-FU based chemotherapy for rectal cancer using Intensity Modulated Radiation Therapy (IMRT) with simultaneous integrated boost (SIB) technique compared to 3D Conformal Radiation Therapy (3DCRT) Methods: Fourty nine (49) consecutive rectal cancer patients treated with pelvic radiation and concurrent 5-FU based chemotherapy were analyzed. We compared twenty-eight (28) patients treated on an institutional IMRT protocol versus twenty-one (21) patients treated with 3DCRT. All patients received 45-50.4 Gy to the pelvis in 3DCRT group. All patients with IMRT received 45 Gy in 25 fractions to the pelvic no des. The primary rectal tumor recieved a simultaneous integrated boost to a dose of 50 Gy in 25 fractions. IMRT planning was done with dose constraints for bladder, rectum, and small bowel and bone marrow. All patients in both groups received 5-FU based chemotherapy during radiation. Evaluation of toxicity was base...

Image-based management of empiric lung stereotactic body radiotherapy (SBRT) without biopsy: Predictors from a 10-year single institution experience: Management of empiric lung SBRT

There is emerging reliance on clinical imaging for the diagnosis, prognosis, and treatment evaluation of early stage non‐small cell lung cancer (NSCLC) in patients deemed too high risk for biopsy. We report our experience of clinically diagnosed NSCLC treated empirically with stereotactic body radiotherapy (SBRT) to validate the imaging parameters used for management in this high‐risk population.

Stereotactic body radiotherapy for central lung tumors: Finding the balance between safety and efficacy in the “no fly” zone: SBRT for central lung tumors

Stereotactic body radiotherapy (SBRT) has emerged as a highly effective technique to treat medically inoperable non‐small cell lung cancer (NSCLC). Doses must be chosen carefully when treating central lesions because of the potential for significant toxicity. This study reviews the outcomes of a cohort of patients with central lung tumors treated with SBRT.

Effect of daily and every other day stereotactic body radiation therapy schedules on treatment-related fatigue in patients with hepatocellular carcinoma

PURPOSE We compared the rate and severity of fatigue in patients who completed stereotactic body radiation therapy (SBRT) to the liver daily (QD) compared with every other day (QOD). METHODS AND MATERIALS From 2010 to 2017, 91 patients with Child Pugh (CP) A (n = 57) or CP-B (n = 34) cirrhosis who completed 100 SBRT sessions to 110 hepatocellular carcinoma (HCC) lesions were analyzed in this study. Confounding variables with fatigue such as CP-C cirrhosis, Eastern Cooperative Oncology Group score >2, or a history of ascites or encephalopathy were excluded. Fatigue was assessed against several treatment- and patient-related variables with univariate and propensity score-matched multivariate analysis. The median follow-up time was 18 months. RESULTS Patients with HCC and Barcelona-Clinic Liver Cancer stages 0 (n = 10), A (n = 32), and B (n = 58), and a median age of 62 years were analyzed. The median tumor diameter was 3 cm (1.1-11 cm). The Eastern Cooperative Oncology Group performance status score was 0 (n = 44), 1 (n = 43), or 2 (n = 13). The median dose was 45 Gy in 5 fractions, and 65 treatments were QD and 45 QOD. Grades 1 and 2 fatigue developed in 49% and 14% of treatments, respectively. Among the patients who were treated daily, 78% developed Grade 1 or 2 fatigue compared with 44% who were treated QOD (odds ratio: 4.52; P = .001). Grade 2 fatigue occurred in 22% of patients compared with 7.3% for QD and QOD treatment, respectively (odds ratio: 3.83; P = .048). There was no difference in fatigue rate for time of treatment (morning or afternoon), dose, treated volume, CP score, Barcelona-Clinic Liver Cancer stage, or performance status, which were not associated with any level of fatigue. There was no difference in local control between QD and QOD treatments. CONCLUSIONS Compared with traditional daily treatment fractions, SBRT that is delivered QOD to cirrhotic patients with HCC may reduce the risk of fatigue.

SBRT for early stage lung cancer: outcomes from biopsy-proven and empirically treated lesions

Aim: Herein, we compare outcomes in patients treated with lung stereotactic body radiotherapy (SBRT) with and without tissue confirmation. Methods: We reviewed 196 patients that underwent lung SBRT for presumed (100 patients) or proven non-small-cell lung cancer (96 patients) over a 10-year period and compared outcomes. Results: A total of 196 patients with a median age of 76 underwent lung SBRT to a median dose of 48 Gy in four fractions. Median follow up was 17 months. Local control and overall survival at 3 years was 94 and 58% for the entire group. There was no difference in overall survival, local control, regional control or distant control between the cohorts. Conclusion: SBRT is a safe and effective treatment for patients with non-small-cell lung cancer that are medically inoperable with comparable results in empirically treated patients.

Dose escalation and associated predictors of survival with consolidative thoracic radiotherapy in extensive stage small cell lung cancer (SCLC): A National Cancer Database (NCDB) propensity-matched analysis

PURPOSE Randomized studies have demonstrated a survival benefit for consolidative thoracic radiotherapy (TRT) in extensive stage (ES) small cell lung cancer (SCLC), however the radiation dose and optimal selection criteria are often debated. METHODS We analyzed 3280 stage IV SCLC treated with double-agent chemotherapy and TRT within the National Cancer Data Base (NCDB) and evaluated the differences in selection patterns and survival outcomes for patients who received at least 45 Gy of TRT and those who received <45 Gy. Univariable and multivariable analyses identified characteristics predictive of overall survival. Propensity-adjusted Cox proportional hazard ratios for survival were used to account for indication bias between the two dose arms. RESULTS There were 1621 patients in the <45 Gy group (most common 30 Gy) and 1659 patients in the 45 Gy or higher group (most common 45 Gy). White patients, T1-T3 lesions, an absence of brain/liver/bone metastases, and starting TRT after 12 weeks of chemotherapy were associated with the higher dose group. With multivariable analysis, TRT to at least 45 Gy was an independent predictor of improved survival (HR = 0.78, P < 0.001) along with female gender, age <65, lower comorbidity score, starting TRT 12 weeks after chemotherapy, and the absence of brain/liver/bone metastases (P < 0.01). Propensity adjusted regression model showed a persistent correlation between a higher dose and survival (HR = 0.74, P < 0.001). Survival at 1 and 2 years for the 45 Gy or higher arm was 58.1% and 25.2% compared to 43.8% and 15.1% for the <45 Gy arm (P < 0.001). CONCLUSION In the largest analysis of consolidative thoracic radiotherapy in ES-SCLC to date, dose escalation to at least 45 Gy was an independent predictor for increased survival. These findings may be validated in ongoing prospective studies.

Dose Effect in Adjuvant Radiation Therapy for the Treatment of Resected Keloids

PURPOSE Surgical excision of keloids can result in an insidious cycle of tissue injury and repeat keloid formation unless combined with adjuvant therapy to halt this cycle. We present our results of postoperative radiation therapy for keloids with various dose regimens. METHODS AND MATERIALS A retrospective review of 124 patients with 250 keloid lesions treated with postoperative radiation therapy was analyzed. In this institutional review board-approved study, 125 keloids were treated to 20 Gy in 5 fractions and 125 keloids were treated to 12 to 16 Gy in 3 to 4 fractions. Local failure was defined as redevelopment of any clinically apparent keloid at the treated site. The median age was 34 years (14-84 years). Keloids were located on the ear (34%), neck/shoulder (19%), abdomen (13%), chest (10%), face (9%), breast (7%), extremities (4%), and back (3%). Median keloid size was 4 cm (0.5-20 cm). RESULTS At a median follow-up of 40 months, the recurrence rate for all lesions was 5.6%. Lesions treated to 20 Gy had a recurrence rate of 1.6% compared with 9.6% with <20 Gy and an odds ratio of 0.16 (P = .02). Upon univariate and multivariate analysis there were no differences in recurrence rate with respect to location, race, gender, age, previously treated lesions, and presence of multiple keloids. The lone predictor for improved control rate was the dose of 20 Gy in 5 fractions compared with less than that. Control rate for lesions treated to a biologically equivalent dose2 of 35 to 36 Gy2, 48 to 52.5 Gy2, and 60 to 72 Gy2 were 10% (P = .007), 8.9% (P = .16), and 1.6% (P = .02), respectively. CONCLUSIONS Surgical excision followed by immediate adjuvant radiation therapy for keloids provides excellent local control and cosmesis. Treatment with a biologically equivalent dose2 > 60 (20 Gy in 5 fractions) yielded superior local control over lower dose regimens.

Linear accelerator-based radiosurgery and hypofractionated stereotactic radiotherapy for brain metastasis secondary to gynecologic malignancies: A single institution series examining outcomes of a rare entity

Objective The use of SRS and fSRT to determine overall survival, tumor control, and local-disease free progression in patient diagnosed with gynecologic brain metastasis. Methods In this retrospective review, 11 patients aged 50 to 85 (median age of 71) were treated with linear accelerator-based SRS and hypofractionated SRT for brain metastasis secondary to gynecologic malignancies. In total, 16 tumors were treated from 2007 to 2017. Patients were treated to a median dose of 24 Gy (range 15 to 30 Gy) in 3 Fx (range 1 to 5). Median follow-up from SRS or SRT was 4 months (range 3–38 months). Results The actuarial 1-year overall survival rate was 26% with a median overall survival of 8 months. In addition, 1-year actuarial local control rate was 83.3% and the 1-year distant brain control rate was 31%. One patient experienced toxicity that presented as seizures after 7 months (due to minimal edema) that required anticonvulsants. There was no other acute or late treatment-related toxicity. Conclusion: Linear-accelerator based SRS or fSRT is safe and effective for control of local tumor growth in brain metastases secondary to gynecologic malignancies. The course of disease remains aggressive as seen by poor overall survival and distant failure rate.