Publications by authors named "Chirag Shah"

411 Publications

Disproportionate Negative Impact of the Radiation Oncology Alternative Payment Model on Rural Providers: A Cost Identification Analysis of Medicare Claims.

JCO Oncol Pract 2021 Sep 16:OP2100330. Epub 2021 Sep 16.

Cancer Care Institute at Monument Health, Rapid City, SD.

Purpose: The Radiation Oncology Alternative Payment Model (APM) is a Medicare demonstration project that will test whether prospective bundled payments to a randomly selected group of physician practices, hospital outpatient departments, and freestanding radiation therapy centers reduce overall expenditures while preserving or enhancing the quality of care for beneficiaries. The Model follows a complicated pricing methodology that blends historical reimbursements for a defined set of services made to professional and technical providers to create a weighted payment average for each of 16 cancer types. These averages are then adjusted by various factors to determine APM payments specific to each participating provider.

Methods: This impact study segregates APM participants into rural and urban groups and analyzes the effect of the Radiation Oncology Alternative Payment Model on their fee-for-service reimbursements.

Results: The main findings of this study are (1) the greater net-negative revenue impact on rural facilities versus urban facilities that would have participated in the Model this year and (2) the relative lack of high-value treatment services (ie, stereotactic radiotherapy and brachytherapy) delivered by rural facilities that exacerbates their negative impact.

Conclusion: As such, rural providers participating in the Model in its current form may face greater risk to their economic viability and greater difficulty in funding technology improvements necessary for the achievement of high-quality care compared with their urban counterparts.
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http://dx.doi.org/10.1200/OP.21.00330DOI Listing
September 2021

Cardiac risk stratification in cancer patients: A longitudinal patient-patient network analysis.

PLoS Med 2021 Aug 2;18(8):e1003736. Epub 2021 Aug 2.

Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States of America.

Background: Cardiovascular disease is a leading cause of death in general population and the second leading cause of mortality and morbidity in cancer survivors after recurrent malignancy in the United States. The growing awareness of cancer therapy-related cardiac dysfunction (CTRCD) has led to an emerging field of cardio-oncology; yet, there is limited knowledge on how to predict which patients will experience adverse cardiac outcomes. We aimed to perform unbiased cardiac risk stratification for cancer patients using our large-scale, institutional electronic medical records.

Methods And Findings: We built a large longitudinal (up to 22 years' follow-up from March 1997 to January 2019) cardio-oncology cohort having 4,632 cancer patients in Cleveland Clinic with 5 diagnosed cardiac outcomes: atrial fibrillation, coronary artery disease, heart failure, myocardial infarction, and stroke. The entire population includes 84% white Americans and 11% black Americans, and 59% females versus 41% males, with median age of 63 (interquartile range [IQR]: 54 to 71) years old. We utilized a topology-based K-means clustering approach for unbiased patient-patient network analyses of data from general demographics, echocardiogram (over 25,000), lab testing, and cardiac factors (cardiac). We performed hazard ratio (HR) and Kaplan-Meier analyses to identify clinically actionable variables. All confounding factors were adjusted by Cox regression models. We performed random-split and time-split training-test validation for our model. We identified 4 clinically relevant subgroups that are significantly correlated with incidence of cardiac outcomes and mortality. Among the 4 subgroups, subgroup I (n = 625) has the highest risk of de novo CTRCD (28%) with an HR of 3.05 (95% confidence interval (CI) 2.51 to 3.72). Patients in subgroup IV (n = 1,250) had the worst survival probability (HR 4.32, 95% CI 3.82 to 4.88). From longitudinal patient-patient network analyses, the patients in subgroup I had a higher percentage of de novo CTRCD and a worse mortality within 5 years after the initiation of cancer therapies compared to long-time exposure (6 to 20 years). Using clinical variable network analyses, we identified that serum levels of NT-proB-type Natriuretic Peptide (NT-proBNP) and Troponin T are significantly correlated with patient's mortality (NT-proBNP > 900 pg/mL versus NT-proBNP = 0 to 125 pg/mL, HR = 2.95, 95% CI 2.28 to 3.82, p < 0.001; Troponin T > 0.05 μg/L versus Troponin T ≤ 0.01 μg/L, HR = 2.08, 95% CI 1.83 to 2.34, p < 0.001). Study limitations include lack of independent cardio-oncology cohorts from different healthcare systems to evaluate the generalizability of the models. Meanwhile, the confounding factors, such as multiple medication usages, may influence the findings.

Conclusions: In this study, we demonstrated that the patient-patient network clustering methodology is clinically intuitive, and it allows more rapid identification of cancer survivors that are at greater risk of cardiac dysfunction. We believed that this study holds great promise for identifying novel cardiac risk subgroups and clinically actionable variables for the development of precision cardio-oncology.
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http://dx.doi.org/10.1371/journal.pmed.1003736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8366997PMC
August 2021

American Brachytherapy Society (ABS) consensus statement for soft-tissue sarcoma brachytherapy.

Brachytherapy 2021 Jul 21. Epub 2021 Jul 21.

Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.

Purpose: Growing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS.

Methods And Materials: Members of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience.

Results: Brachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure.

Conclusions: These updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.
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http://dx.doi.org/10.1016/j.brachy.2021.05.011DOI Listing
July 2021

Comment on: Effect of time on quality of parent-child communication in pediatric cancer.

Pediatr Blood Cancer 2021 Jul 21:e29244. Epub 2021 Jul 21.

King's College London, GKT School of Medical Education, London, UK.

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http://dx.doi.org/10.1002/pbc.29244DOI Listing
July 2021

Impact of the Radiation Oncology Alternative Payment Model on Brachytherapy Reimbursement.

Brachytherapy 2021 Jul 5. Epub 2021 Jul 5.

The US Oncology Network, and McKesson Corporation, The Woodlands, TX.

Purpose: The Radiation Oncology Alternative Payment Model (RO Model) will test prospective radiotherapy episode-based payments for 16 common disease sites. We created an automated analytics platform to calculate the impact of the RO Model vs historical fee-for-service episode reimbursements for brachytherapy treatments within five community oncology practices for prostate, uterine, and cervical cancer.

Methods And Materials: Claims data between January 1, 2017 and October 2, 2019 for prostate, uterine, and cervical cancer were analyzed as per the RO Model Final Rule methodology. Expected professional and technical component (PC and TC) reimbursements were compared for episodes that utilized brachytherapy alone vs combination modality (external beam and brachytherapy) in the RO Model vs historical reimbursements.

Results: 6,022 RO Model-defined episodes (60% prostate, 28% uterine, 13% cervical) were generated. Brachytherapy monotherapy episodes (14%) would have an average positive reimbursement in the RO Model (+$2,163 for prostate, +$711 for uterine, +$533 for cervical for the PC; +$12,168 for prostate, +$8,181 for uterine, +$11,322 for cervical for the TC), while combination modality episodes (15%) would have an average negative reimbursement in the RO Model (-$183 for prostate, -$1,701 for uterine, -$2,195 for cervical for the PC; -$374 for prostate, -$5,026 for uterine, -$2,801 for cervical for the TC).

Conclusions: Brachytherapy monotherapy episodes for prostate, uterine, and cervical cancer will benefit from an increase in payment, whereas combination modality episodes will receive lower reimbursement. Large shifts in episodic payment may be related to practice-wide adjustments and pricing based on partial episodes of care that may ultimately limit access to care for vulnerable patient populations with cancer.
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http://dx.doi.org/10.1016/j.brachy.2021.05.003DOI Listing
July 2021

Understanding the Evolving Continuing Medical Education Needs of Physicians Managing Patients with TD.

CNS Spectr 2021 04;26(2):149

Neurocrine Biosciences, Inc., San Diego, CA, USA.

This study sought to understand the evolving continuing medical education (CME) needs of physicians managing patients with tardive dyskinesia (TD). A case-based survey was developed, and later updated, to assess current practice, knowledge, and attitudes of neurologists and psychiatrists in the management of patients with TD. The original and updated survey were fielded in May 2018 and March 2020, respectively, to US-practicing psychiatrists and neurologists. Results were obtained from 213 psychiatrists and 187 neurologists in 2018 and from 125 psychiatrists and 128 neurologists in 2020. Less than half of physicians in both 2018 and 2020 were able to correctly identify the prevalence of TD in patients on maintenance antipsychotics, with many underestimating reported prevalence. Respondents reported moderate familiarity with VMAT2 inhibitor therapies for TD, with self-reported familiarity increasing more among neurologists than psychiatrists since the 2018 study. Psychiatrists are more likely than neurologists to take responsibility for medical management of TD symptoms and antipsychotic medication adjustment. Despite recommendations from APA guidelines and AAN reviews, 15% of physicians would use an anticholinergic to manage TD symptoms and only about half would opt for a VMAT2 inhibitor. There was a larger increase in VMAT inhibitor use between 2018 and 2020 among neurologists as compared to psychiatrists. The findings support the need for CME on TD focused toward specific provider groups. While both types of specialists would benefit from CME on the topic of TD epidemiology, there is an increased need for CME that includes treatment updates among psychiatrists.Funding. Neurocrine Biosciences, Inc.
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http://dx.doi.org/10.1017/S1092852920002369DOI Listing
April 2021

Challenges in Treating Tardive Dyskinesia: Assessing the Impact of Virtual Medical Education.

CNS Spectr 2021 04;26(2):165

Global Medical Education, New York, NY, USA.

Introduction: Tardive Dyskinesia (TD) refers to abnormal, involuntary, choreoathetoid movements of the tongue, lips, face, trunk, and extremities and is associated with long-term exposure to dopamine-blocking agents, such as antipsychotic medications. Once established, these movements usually persist. The movements are disfiguring and can bring unwanted attention to affected individuals. When severe, especially if the respiratory muscles are affected, the movements can be disabling, limit activity, and reduce quality of life. The prevalence is 7.2% in individuals on newer antipsychotics who have never been exposed to older neuroleptics. Until recently, there were no effective treatments for TD. In recent years, many new treatments have been investigated for the treatment of TD, including valbenazine, deutetrabenazine, and branched chain amino acids. Valbenazine first, followed by deutetrabenazine are FDA approved to treat TD. A virtual broadcast was developed to assess the ability of continuing medical education (CME) to improve awareness of the recognition and treatment of TD among psychiatrists.

Methods: The virtual broadcast (May 9, 2020) consisted of a two-hour, live-streamed discussion between two expert faculty. Impact of the educational activity was assessed by comparing psychiatrists' responses to four identical questions presented before and directly after activity participation. A follow-up survey was sent to all participants six-weeks post-activity to measure performance in practice changes. A chi-square test was used to identify significant differences between pre- and post-assessment responses. Cohen's d was used to calculate the effect size of the virtual broadcast.

Results: Activity participation resulted in a noticeable educational effect among psychiatrists (n=621; d=6.12, P<.001). The following areas showed significant (P<0.05) pre- vs post-educational improvements: recognition of movements in patients with TD, rate of TD in SGA exposed patients, treatment options for TD (on and off-label), and treatment of TD using VMAT inhibitors. Additionally, 54% of psychiatrists reported a change in practice performance as a result of the education received in the activity, including utilization of a standard scale to evaluate movement disorders and educate patients and family members about potential for TD, how to recognize symptoms, and when to treat.

Conclusions: The results indicated that a CME-certified two-hour virtual broadcast was effective at improving knowledge among psychiatrists for the recognition and treatment of TD. This knowledge also resulted in positive changes in practice performance post-activity. Future education should continue to address best practices in the diagnosis, treatment and management of patients with TD, as there remains an increased need for tailored CME among psychiatrists.

Funding: Neurocrine Biosciences, Inc.
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http://dx.doi.org/10.1017/S1092852920002667DOI Listing
April 2021

Using Item 8 of the Abnormal Involuntary Movement Scale (AIMS) to Assess Improvement in Patients with Tardive Dyskinesia.

CNS Spectr 2021 04;26(2):152

Neurocrine Biosciences, Inc., San Diego, CA, USA.

Objective: The Abnormal Involuntary Movement Scale (AIMS) total score (sum of items 1-7) is usually the primary efficacy measure in tardive dyskinesia (TD) clinical trials. However, item 8 of the AIMS (clinician's global impression of severity) might also be an appropriate assessment in real-life healthcare settings. To explore the potential of item 8 as a clinical measure, post hoc analyses were conducted using data from a long-term study of valbenazine, an approved TD medication.

Methods: In KINECT 4 (NCT02405091), adults with TD received once-daily valbenazine (40 or 80 mg) for 48 weeks. Analyses included two sets of AIMS item 8 scores: based on investigators ratings of item 8 using protocol-defined descriptors; and based on investigators highest scores from items 1-7 (analyzed post hoc). Shift analyses included an improvement from score =3 at baseline (moderate or severe) to score =2 at Week 48 (none to mild).

Results: At baseline in all participants (N=163), AIMS item 8 mean scores were 3.2 (protocol) and 3.3 (post hoc). In participants with a score =3 at baseline per investigators ratings using protocol-defined descriptors, 95.9% [94/98] shifted to a score =2 by Week 48. A similar result (93.9% [93/99]) was found when item 8 was based on investigators highest scores from items 1-7.

Conclusion: Shift analyses using AIMS item 8 scores indicated that most participants in KINECT 4 had a clinically meaningful improvement after 48 weeks of once-daily treatment with valbenazine. AIMS item 8 may be an appropriate clinical measure for assessing changes in TD severity.

Funding: Neurocrine Biosciences, Inc.
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http://dx.doi.org/10.1017/S1092852920002424DOI Listing
April 2021

Knowledge of The Recognition and Management of Tardive Dyskinesia Markedly Improved Among Psychiatrists: Assessing the Impact of Online Medical Education.

CNS Spectr 2021 04;26(2):153-154

Neuroscience Education Institute, Chief Medical Officer, Carlsbad, CA, USA and SUNY Upstate Medical University, Clinical Associate Professor of Psychiatry, Syracuse, NY, USA.

Introduction: Tardive dyskinesia (TD) is a persistent and potentially disabling movement disorder associated with prolonged exposure to antipsychotic medications that jeopardizes adherence to treatment and reduces quality of life. The recognition and management of TD can be challenging in many instances. An online activity was developed to assess the ability of continuing medical education (CME) to improve awareness of the recognition and management of TD among psychiatrists.

Methods: The online CME activity consisted of a 30-minute video discussion between three expert faculty. Educational effect was assessed by comparing a matched sample of psychiatrists' responses to four identical questions pre- and post-activity. A chi-square test identified significant differences between pre- and post-assessment responses. Cramer's V was used to calculate the effect size of the online education (≥ 0.16 is considerable). Data were collected between June 26 and August 6, 2019.

Results: Activity participation resulted in a considerable educational effect among psychiatrists (n=739; V=0.25, P<0.001). The following areas showed significant (P <0.05) pre- vs post-educational improvements: recognition of incidence of TD associated with different antipsychotic therapies, differentiation of TD from parkinsonism, and the personalized selection of therapies for the management of TD. 37% of psychiatrists had a measurable increase in confidence in understanding the role of the interprofessional team in recognizing TD after activity participation.

Conclusions: The results indicated that a CME-certified 30-minute video activity was effective at improving knowledge among psychiatrists for the recognition and management of TD. Future education should continue to address best practices in the care of patients with TD.

Funding: Neurocrine Bioscience, Inc.
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http://dx.doi.org/10.1017/S1092852920002448DOI Listing
April 2021

Onset and Resolution of Key Adverse Events in Valbenazine-Treated Patients with Tardive Dyskinesia: Pooled Analyses from Two Long-Term Clinical Trials.

CNS Spectr 2021 04;26(2):151

Neurocrine Biosciences, Inc., San Diego, CA, USA.

Objective: Tardive dyskinesia (TD) is a persistent and potentially disabling movement disorder associated with prolonged exposure to antipsychotics and other dopamine receptor blocking agents. Long-term safety of the approved TD medication, valbenazine, was demonstrated in 2 clinical trials (KINECT 3 [NCT02274558], KINECT 4 [NCT02405091]). Data from these trials were analyzed post hoc to evaluate the onset and resolution of adverse events (AEs).

Methods: Participants in KINECT 3 and KINECT 4 received up to 48 weeks of once-daily valbenazine (40 or 80 mg). Data from these studies were pooled and analyzed to assess the incidence, time to first occurrence, and resolution for the following AEs of potential clinical interest: akathisia, balance disorder, dizziness, parkinsonism, somnolence/sedation, suicidal behavior/ideation, and tremor.

Results: In the pooled population (N=314), all AEs of potential clinical interest occurred in <10% of participants, with somnolence (9.6%), suicidal behavior/ideation (6.4%), and dizziness (5.7%) being the most common AEs. Mean time to first occurrence ranged from 36 days (akathisia [n=9]) to 224 days (parkinsonism [n=2]). By end of study (or last study visit), resolution of AEs was as follows: 100% (suicidal ideation/behavior, parkinsonism); >85% (somnolence/sedation, dizziness); >70% (akathisia, balance disorder, tremor).

Conclusions: In long-term clinical trials, the incidence of AEs of potential clinical interest was low (<10%) and most were resolved by end of treatment (>70-100%). All patients taking valbenazine should be routinely monitored for AEs, particularly those that may exacerbate the motor symptoms associated with TD.

Funding: Neurocrine Biosciences, Inc.
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http://dx.doi.org/10.1017/S1092852920002394DOI Listing
April 2021

Assessment of the Association of COPD and Asthma with In-Hospital Mortality in Patients with COVID-19. A Systematic Review, Meta-Analysis, and Meta-Regression Analysis.

J Clin Med 2021 May 13;10(10). Epub 2021 May 13.

Albert Einstein College of Medicine, Bronx, NY 10461, USA.

Together, chronic obstructive pulmonary disease (COPD) and asthma account for the most common non-infectious respiratory pathologies. Conflicting preliminary studies have shown varied effect for COPD and asthma as prognostic factors for mortality in coronavirus disease 2019 (COVID-19). The aim of this study was to explore the association of COPD and asthma with in-hospital mortality in patients with COVID-19 by systematically reviewing and synthesizing with a meta-analysis the available observational studies. MEDLINE, Scopus, and medRxiv databases were reviewed. A random-effects model meta-analysis was used, and I-square was utilized to assess for heterogeneity. In-hospital mortality was defined as the primary endpoint. Sensitivity and meta-regression analyses were performed. Thirty studies with 21,309 patients were included in this meta-analysis (1465 with COPD and 633 with asthma). Hospitalized COVID-19 patients with COPD had higher risk of death compared to those without COPD (OR: 2.29; 95% CI: 1.79-2.93; I 59.6%). No significant difference in in-hospital mortality was seen in patients with and without asthma (OR: 0.87; 95% CI: 0.68-1.10; I 0.0%). The likelihood of death was significantly higher in patients with COPD that were hospitalized with COVID-19 compared to patients without COPD. Further studies are needed to assess whether this association is independent or not. No significant difference was demonstrated in COVID-19-related mortality between patients with and without asthma.
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http://dx.doi.org/10.3390/jcm10102087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8152460PMC
May 2021

The Influence of Universal Face Mask Use on Endophthalmitis Risk after Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

Ophthalmology 2021 May 18. Epub 2021 May 18.

Wills Eye Hospital, Philadelphia, Pennsylvania. Electronic address:

Purpose: Routine use of face masks for patients and physicians during intravitreal anti-vascular endothelial growth factor (VEGF) injections has increased with the emergence of the coronavirus disease 2019 pandemic. This study evaluates the impact of universal face mask use on rates and outcomes of post-injection endophthalmitis (PIE).

Design: Retrospective, multicenter, comparative cohort study.

Participants: Eyes receiving intravitreal anti-VEGF injections from October 1, 2019, to July 31, 2020, at 12 centers.

Methods: Cases were divided into a "no face mask" group if no face masks were worn by the physician or patient during intravitreal injections or a "universal face mask" group if face masks were worn by the physician, ancillary staff, and patient during intravitreal injections.

Main Outcome Measures: Rate of endophthalmitis, microbial spectrum, and visual acuity (VA).

Results: Of 505 968 intravitreal injections administered in 110 547 eyes, 85 of 294 514 (0.0289%; 1 in 3464 injections) cases of presumed endophthalmitis occurred in the "no face mask" group, and 45 of 211 454 (0.0213%; 1 in 4699) cases occurred in the "universal face mask" group (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.51-1.18; P = 0.097). In the "no face mask" group, there were 27 cases (0.0092%; 1 in 10 908 injections) of culture-positive endophthalmitis compared with 9 cases (0.004%; 1 in 23 494) in the "universal face mask" group (OR, 0.46; 95% CI, 0.22-0.99; P = 0.041). Three cases of oral flora-associated endophthalmitis occurred in the "no face mask" group (0.001%; 1 in 98 171 injections) compared with 1 (0.0005%; 1 in 211 454) in the "universal face mask" group (P = 0.645). Patients presented a mean (range) 4.9 (1-30) days after the causative injection, and mean logarithm of the minimum angle of resolution (logMAR) VA at endophthalmitis presentation was 2.04 (~20/2200) for "no face mask" group compared with 1.65 (~20/900) for the "universal face mask" group (P = 0.022), although no difference was observed 3 months after treatment (P = 0.764).

Conclusions: In a large, multicenter, retrospective study, physician and patient face mask use during intravitreal anti-VEGF injections did not alter the risk of presumed acute-onset bacterial endophthalmitis, but there was a reduced rate of culture-positive endophthalmitis. Three months after presentation, there was no difference in VA between the groups.
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http://dx.doi.org/10.1016/j.ophtha.2021.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130590PMC
May 2021

Cost-Effectiveness Analysis of No Adjuvant Therapy Versus Partial Breast Irradiation Alone Versus Combined Treatment for Treatment of Low-Risk DCIS: A Microsimulation.

JCO Oncol Pract 2021 Aug 10;17(8):e1055-e1074. Epub 2021 May 10.

Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.

Purpose: Adjuvant therapy in patients with ductal carcinoma in situ who undergo partial mastectomy remains controversial, particularly for low-risk patients (60 years or older, estrogen-positive, tumor extent < 2.5 cm, grade 1 or 2, and margins ≥ 3 mm). We performed a cost-effectiveness analysis comparing three strategies: no adjuvant treatment after surgery, a five-fraction course of accelerated partial breast irradiation using intensity-modulated radiation therapy (accelerated partial breast irradiation [APBI]-alone), or APBI plus an aromatase inhibitor for 5 years.

Materials And Methods: Outcomes including local recurrence, distant metastases, and survival as well as toxicity data were modeled by a patient-level Markov microsimulation model, which were validated against trial data. Costs of treatment and possible adverse events were included from the societal perspective over a lifetime horizon, adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALYs) were calculated based on utilities extracted from the literature.

Results: No adjuvant therapy was the least costly approach ($5,744), followed by APBI-alone ($11,070); combined therapy was costliest ($16,052). Adjuvant therapy resulted in slightly higher QALYs (no adjuvant, 11.320; APBI-alone, 11.343; and combination, 11.381). In the base case, no treatment was the cost-effective strategy, with an incremental cost-effectiveness ratio of $239,109/QALY for APBI-alone and $171,718/QALY for combined therapy. The incremental cost-effectiveness ratio for combined therapy compared with APBI-alone was $131,949. Probabilistic sensitivity analyses found that no therapy was cost effective (defined as $100,000/QALY of lower) in 63% of trials, APBI-alone in 19%, and the combination in 18%.

Conclusion: No adjuvant therapy represents the most cost-effective approach for postmenopausal women 60 years or older who receive partial mastectomy for low-risk ductal carcinoma in situ.
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http://dx.doi.org/10.1200/OP.20.00992DOI Listing
August 2021

Dosimetric Comparison of Radiation Techniques for Comprehensive Regional Nodal Radiation Therapy for Left-Sided Breast Cancer: A Treatment Planning Study.

Front Oncol 2021 12;11:645328. Epub 2021 Apr 12.

Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.

Purpose: How modern cardiac sparing techniques and beam delivery systems using advanced x-ray and proton beam therapy (PBT) can reduce incidental radiation exposure doses to cardiac and pulmonary organs individually or in any combination is poorly investigated.

Methods: Among 15 patients with left-sided breast cancer, partial wide tangential 3D-conformal radiotherapy (3DCRT) delivered in conventional fractionation (CF) or hypofractionated (HF) schedules; PBT delivered in a CF schedule; and volumetric modulated arc therapy (VMAT) delivered in an HF schedule, each under continuous positive airway pressure (CPAP) and free-breathing (FB) conditions, were examined. Target volume coverage and doses to organs-at-risk (OARs) were calculated for each technique. Outcomes were compared with one-way analysis of variance and the Bonferroni test, with -values <0.05 considered significant.

Results: Target volume coverage was within acceptable levels in all interventions, except for the internal mammary lymph node D95 (99% in PBT, 90% in VMAT-CPAP, 84% in VMAT-FB, and 74% in 3DCRT). The mean heart dose (MHD) was the lowest in PBT (<1 Gy) and VMAT-CPAP (2.2 Gy) and the highest in 3DCRT with CF/FB (7.8 Gy), respectively. The mean lung dose (MLD) was the highest in 3DCRT-CF-FB (20 Gy) and the lowest in both VMAT-HF-CPAP and PBT (approximately 5-6 Gy). VMAT-HF-CPAP and PBT delivered a comparable maximum dose to the left ascending artery (7.2 and 6.13 Gy, respectively).

Conclusions: Both proton and VMAT in combination with CPAP can minimize the radiation exposure to heart and lung with optimal target coverage in regional RT for left-sided breast cancer. The clinical relevance of these differences is yet to be elucidated. Continued efforts are needed to minimize radiation exposures during RT treatment to maximize its therapeutic index.
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http://dx.doi.org/10.3389/fonc.2021.645328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072050PMC
April 2021

The Clinical Utility of DCISionRT on Radiation Therapy Decision Making in Patients with Ductal Carcinoma In Situ Following Breast-Conserving Surgery.

Ann Surg Oncol 2021 Apr 5. Epub 2021 Apr 5.

GenesisCare, Michigan Healthcare Professionals, Farmington Hills, MI, USA.

Background: The role of radiation therapy (RT) following breast-conserving surgery (BCS) in ductal carcinoma in situ (DCIS) remains controversial. Trials have not identified a low-risk cohort, based on clinicopathologic features, who do not benefit from RT. A biosignature (DCISionRT) that evaluates recurrence risk has been developed and validated. We evaluated the impact of DCISionRT on clinicians' recommendations for adjuvant RT.

Methods: The PREDICT study is a prospective, multi-institutional, observational registry in which patients underwent DCISionRT testing. The primary endpoint was to identify the percentage of patients where testing led to a change in RT recommendations.

Results: Overall, 539 women were included in this study. Pre DCISionRT testing, RT was recommended to 69% of patients; however, post-testing, a change in the RT recommendation was made for 42% of patients compared with the pre-testing recommendation; the percentage of women who were recommended RT decreased by 20%. For women initially recommended not to receive an RT pre-test, 35% had their recommendation changed to add RT following testing, while post-test, 46% of patients had their recommendation changed to omit RT after an initial recommendation for RT. When considered in conjunction with other clinicopathologic factors, the elevated DCISionRT score risk group (DS > 3) had the strongest association with an RT recommendation (odds ratio 43.4) compared with age, grade, size, margin status, and other factors.

Conclusions: DCISionRT provided information that significantly changed the recommendations to add or omit RT. Compared with traditional clinicopathologic features used to determine recommendations for or against RT, the factor most strongly associated with RT recommendations was the DCISionRT result, with other factors of importance being patient preference, tumor size, and grade.
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http://dx.doi.org/10.1245/s10434-021-09903-1DOI Listing
April 2021

HRCT chest in COVID-19 patients: An initial experience from a private imaging center in western India.

Indian J Radiol Imaging 2021 Jan 23;31(Suppl 1):S182-S186. Epub 2021 Jan 23.

EDiR / Sahyog Imaging Centre, Department of Radiodiagnosis, PDU Medical College and Government Hospital, Rajkot, Gujarat, India.

The COVID-19 pandemic began in late December in 2019 and has now reached to 216 countries with 1,08,42,028 confirmed cases and 5,21,277 deaths according to the WHO reports and 6,49,666 confirmed cases in india alone with 18,679 deaths (as on 04 july 2020). RT-PCR has been considered the standard test for diagnosis of COVID 19. However, there has been reported a high false negative rate. This high false negative rate increases the risk of further transmission as well as delays the timely management of suspected cases. We have conducted HRCT chest of various (200 patient case study) proven and suspected cases of COVID-19 infection in the months of April, May and June 2020. Out of 200 scanned patients with clinical complains and suspicion, positive HRCT chest findings were seen in 196 patients, showing clinical-radiological correlation and an accuracy of 98%. The sensitivity of chest CT in suggesting COVID-19 was 98.6% (146/148patients) based on positive RT-PCR results. In patients with negative RT-PCR results and high clinical suspicion, 90% (18/20) had positive chest CT findings. HRCT chest is very sensitive and accurate in picking up lung parenchymal abnormalities in laboratory negative RT-PCR cases with high clinical suspicion of COVID-19 infection and also in all symptomatic patients where RT-PCR was not done. HRCT can also be very sensitive, cost effective and time effective in screening patients with high clinical suspicion. HRCT scores over RT-PCR in giving immediate results, assessing severity of disease and prediction of prognosis. We suggest HRCT chest for detection of early parenchymal abnormalities, assessing severity of disease in all patients with clinical symptoms and suspicion of COVID infection irrespective of laboratory RT-PCR status.
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http://dx.doi.org/10.4103/ijri.IJRI_405_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996681PMC
January 2021

Does CT help in reducing RT-PCR false negative rate for COVID-19?

Indian J Radiol Imaging 2021 Jan 23;31(Suppl 1):S80-S86. Epub 2021 Jan 23.

Department of Radiodiagnosis, LTMMC Sion Hospital, Mumbai, India.

Background: Early detection is the key to contain the ongoing pandemic. The current gold standard to detect SARS CoV2 is RT-PCR. However, it has a high false negative rate and long turnaround time.

Purpose: In view of the high sensitivity of CT in detection of lower respiratory tract pathologies, a study of 2581 patients comparing RT-PCR status with CT findings was undertaken to see if it augments the diagnostic performance.

Materials And Methods: A multi centre prospective study of consecutive cases was conducted. All CT studies suggestive of COVID 19 pneumonia were collated and evaluated independently by three Radiologists to confirm the imaging diagnosis of COVID-19 pneumonia. The RT-PCR values were retrospectively obtained, based on the RT-PCR values, CT studies were categorised into three subgroups, positive, negative and unknown. CT features from all three groups were compared to evaluate any communality or discordance.

Results: Out of the 2581 patients with positive CT findings for COVID pneumonia, 825 were females and 1,756 were males in a wide age group of 28-90 years. Predominant CT features observed in all the subgroups were Ground glass densities 94.8%, in mixed distribution (peripheral and central) (59.12%), posterior segments in 92% and multilobar involvement in 70.9%. The CT features across the three subgroups were statistically significant with a value <0.001.

Conclusion: There was a communality of CT findings regardless of RT-PCR status. In a pandemic setting ground glass densities in a subpleural, posterior and basal distribution are indicative of COVID 19. Thus CT chest in conjunction to RT PCR augments the diagnosis of COVID 19 pneumonia; utilization of CT chest may just be the missing link in closing this pandemic.
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http://dx.doi.org/10.4103/ijri.IJRI_739_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996706PMC
January 2021

Chicken Little or Goose-is-Cooked? The State of the US Radiation Oncology Workforce: Workforce Concerns in US Radiation Oncology.

Int J Radiat Oncol Biol Phys 2021 06 11;110(2):268-271. Epub 2021 Mar 11.

Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

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http://dx.doi.org/10.1016/j.ijrobp.2020.11.056DOI Listing
June 2021

First-in-human study of inhaled Azacitidine in patients with advanced non-small cell lung cancer.

Lung Cancer 2021 04 17;154:99-104. Epub 2021 Feb 17.

Department of Oncology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY10461, USA. Electronic address:

Background: Aerosolized Azacitidine has been shown to inhibit orthotopic lung cancer growth and induce re-expression of methylated tumor suppressor genes in murine models. We hypothesized that inhaled Azacitidine is safe and effective in reversing epigenetic changes in the bronchial epithelium secondary to chronic smoking.

Patients And Methods: We report the first in human study of inhaled Azacitidine. Azacitidine in aqueous solution was used to generate an aerosol suspension of 0.25-5 μm particle size. Main inclusion criteria: Stage IV or recurrent NSCLC with predominantly lung involvement, ≥1 prior systemic therapy, ECOG PS 0-1, and adequate pulmonary function. Patients received inhaled Azacitidine daily on days 1-5 and 15-19 of 28-day cycles, at 3 escalating doses (15, 30 and 45 mg/m daily). The primary objective was to determine the feasibility and tolerability of this new therapeutic modality. The key secondary objectives included pharmacokinetics, methylation profiles and efficacy.

Results: From 3/2015 to 2/2018, eight patients received a median number of 2 (IQR = 1) cycles of inhaled Azacitidine. No clinically significant adverse events were observed, except one patient treated at the highest dose developed an asymptomatic grade 2 decreased DLCO which resolved spontaneously. One patient receiving 12 cycles of therapy had an objective and durable partial response, and two patients had stable disease. Plasma Azacitidine was only briefly detectable in patients treated at the higher doses. Moreover, in 2 of 3 participants who agreed and underwent pre- and post-treatment bronchoscopy, the global DNA methylation in the bronchial epithelium decreased by 24 % and 79 % post-therapy, respectively. The interval between last inhaled treatment and bronchoscopy was 3 days.

Conclusions: Inhaled Azacitidine resulted in negligible plasma levels compared to the previously reported subcutaneous administration and was well-tolerated. The results justify the continued development of inhaled Azacitidine at non-cytotoxic doses for patients with lung-confined malignant and/or premalignant lesions.
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http://dx.doi.org/10.1016/j.lungcan.2021.02.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026712PMC
April 2021

Hypofractionated volumetric-modulated arc therapy for breast cancer: A propensity-score-weighted comparison of radiation-related toxicity.

Int J Cancer 2021 07 8;149(1):149-157. Epub 2021 Mar 8.

Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.

We assessed the clinical benefit of combining volumetric-modulated arc therapy (VMAT) and hypofractionated radiotherapy (HF-RT) considering the incidence of radiation-related toxicities. After a retrospective review for breast cancer patients treated with adjuvant RT between 2005 and 2017, a total of 4209 patients treated with three-dimensional conventional fractionation (CF-3D, 50.4 Gy/28 fractions) and 1540 patients treated with HF-RT (768 received HF-3D; 772, HF-VMAT; 40 Gy/15 fractions) were included. A total of 2229 patients (38.8%) received regional node irradiation (RNI): 1642 (39.0%), 167 (21.7%) and 420 (54.4%) received RNI via CF-3D, HF-3D and HF-VMAT, respectively. Acute/subacute and late toxicities were evaluated. Propensity scores were calculated via logistic regression. Grade 2+ acute/subacute toxicities was the highest in CF-3D group (15.0%, 2.6% and 1.6% in CF-3D, HF-3D and HF-VMAT, respectively; P < .001). HF-VMAT reduced Grade 2+ acute/subacute toxicities significantly compared to CF-3D (odds ratio [OR] 0.11, P < .001) and HF-3D (OR 0.45, P = .010). The 3-year cumulative rate of late toxicities was 18.0% (20.1%, 10.9% and 13.4% in CF-3D, HF-3D and HF-VMAT, respectively; P < .001). On sensitivity analysis, the benefit of HF-VMAT was high in the RNI group. Acute and late toxicities were fewer after HF-VMAT than after HF-3D or CF-3D, especially in women who underwent RNI.
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http://dx.doi.org/10.1002/ijc.33525DOI Listing
July 2021

Reducing time to treatment and patient costs with breast cancer: the impact of patient visits.

Breast J 2021 03 3;27(3):237-241. Epub 2021 Feb 3.

Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.

Background: The purpose of this study was to evaluate the impact of processes aimed at reducing time to treatment initiation (TTI) on minimizing the days spent to complete pretreatment visits and the associated costs for patients with nonmetastatic breast cancer.

Methods: System-wide initiatives were implemented in 2014 to minimize TTI, by incorporating multiple strategies (eg, creation of teams, patient liaisons, process mapping) and enhanced communication to increase coordinated visits. Average number of days spent to complete visits, TTI, and associated patient costs including driving expenses, parking, food, childcare, and lost wages were calculated and compared between the years 2015 and 2018.

Results: In 2015, the median TTI was 43.5 days and the average number of separate days spent to attend multidisciplinary visits prior to first treatment was 1.86. These were reduced to 29 days and 1.52 visits, respectively, in 2018 (p < 0.0001 for both). When evaluating treatment visits by surgical procedure, the average number of visits was reduced regardless of surgical procedure. The average number of visits was highest for patients undergoing mastectomy with reconstruction (2.34 in 2015, reduced to 1.65 in 2018, p < 0.0001). A single visit to complete treatment planning was associated with patient costs of $249 as compared with multiple trips costing $491 for 2 visits and up to $1,226 for 5 visits.

Conclusions: In breast cancer patients, implementing processes to reduce time to treatment was associated with fewer visits required prior to treatment initiation, resulting in lower patient costs.
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http://dx.doi.org/10.1111/tbj.14174DOI Listing
March 2021

Comment on: 'Increases in arm volume predict lymphoedema and quality of life deficits after axillary surgery: a prospective cohort study.'

Br J Cancer 2021 04 2;124(9):1606-1607. Epub 2021 Feb 2.

21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI, USA.

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http://dx.doi.org/10.1038/s41416-021-01267-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076231PMC
April 2021

In Regard to Dooley et al.

Int J Radiat Oncol Biol Phys 2021 03;109(3):834-835

Helen F. Graham Cancer Center ChristianaCare Health System, Newark, Delaware.

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http://dx.doi.org/10.1016/j.ijrobp.2020.10.027DOI Listing
March 2021

Risk Factors for Prolonged Opioid Use After Open Treatment of Distal Radius Fractures.

Hand (N Y) 2021 Jan 25:1558944720988103. Epub 2021 Jan 25.

Northwestern University, Chicago, IL, USA.

Background: The objective of this study was to evaluate factors associated with postoperative opioid use after open treatment of distal radius fractures.

Methods: The Humana insurance claims database was queried for open treatment of distal radius fractures by Current Procedural Terminology codes. The search was further refined to identify patients who filled an opioid prescription within 6 weeks after their surgery. The study's outcomes were: (1) limited postoperative opioid use, defined as filling a prescription once in the 6-week to 6-month period after surgery; and (2) persistent postoperative opioid use, defined as filling a prescription more than once in the 6-week to 6-month period after surgery. Logistic regression models were performed to identify factors associated with limited and persistent postoperative opioid use. Subgroup analyses were performed among opioid-naïve patients and those with open fractures.

Results: This study identified 9141 of 19 220 total patients with limited and persistent opioid use. Significant risk factors included nonhome discharge, inpatient surgical setting, long-term pain, tobacco abuse, and age less than 65 years. Of note, both preoperative opioid use within 1 month before surgery (odds ratio [OR], 2.6; 95% confidence interval [CI], 2.2-2.9) and preoperative opioid use between 1 and 6 months before surgery (OR, 4.0; 95% CI, 3.7-4.4) were significantly associated with persistent postoperative opioid use.

Conclusions: This study has identified numerous risk factors associated with postoperative opioid use after open treatment of distal radius fractures. Understanding these risk factors is the first step toward reducing postoperative opioid use.
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http://dx.doi.org/10.1177/1558944720988103DOI Listing
January 2021

Ultra-Short Fraction Schedules as Part of De-intensification Strategies for Early-Stage Breast Cancer.

Ann Surg Oncol 2021 Sep 13;28(9):5005-5014. Epub 2021 Jan 13.

Michigan Healthcare Professionals, GenesisCare, Farmington Hills, MI, USA.

Adjuvant radiation therapy (RT) following breast-conserving surgery (BCS) represents a standard approach for most patients treated with breast-conserving therapy (BCT) for early-stage breast cancer. The first-generation of adjuvant RT schedules delivered daily treatment to the whole breast over 5-7 weeks. Although efficacious, this presented patients with a protracted course of treatment, reducing compliance and quality of life. While hypofractionated whole-breast irradiation (WBI) has become the standard, and part of the second-generation of RT regimens, it still requires 3-4 weeks. Concurrently, partial-breast irradiation (PBI) has also been explored as a technique to complete RT in a much shorter time period (1-3 weeks). There are now seven trials confirming the efficacy of this shorter treatment approach compared with standard WBI. In an effort to further reduce treatment duration, ultra-short WBI and PBI regimens have recently emerged as the third-generation of breast radiation schedules, allowing for the completion of treatment in 5 days or less. With respect to WBI, recent data from the FAST-Forward trial (which evaluated five fractions of WBI delivered in 1 week) demonstrated no difference in clinical outcomes at 5 years, with limited difference in toxicity, compared with hypofractionated 3-week WBI. Regarding PBI, published data on five-fraction regimens delivered in 2 weeks have also demonstrated comparable outcomes at 10 years, with reduced toxicities with long-term follow-up. This report will review additional ongoing studies evaluating even shorter courses of adjuvant RT treatment (one to five fractions), including single-fraction PBI or WBI.
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http://dx.doi.org/10.1245/s10434-020-09526-yDOI Listing
September 2021

TARGIT-R (Retrospective): 5-Year Follow-Up Evaluation of Intraoperative Radiation Therapy (IORT) for Breast Cancer Performed in North America.

Ann Surg Oncol 2021 May 12;28(5):2512-2521. Epub 2021 Jan 12.

St. Luke's University Health Network, Bethlehem, PA, USA.

Background: Intraoperative radiation therapy (IORT) has been investigated for patients with low-risk, early-stage breast cancer. The The North American experience was evaluated by TARGIT-R (retrospective) to provide outcomes for patients treated in "real-world" clinical practice with breast IORT. This analysis presents a 5-year follow-up assessment.

Methods: TARGIT-R is a multi-institutional retrospective registry of patients who underwent lumpectomy and IORT between the years 2007 and 2013. The primary outcome of the evaluation was ipsilateral breast tumor recurrence (IBTR).

Results: The evaluation included 667 patients with a median follow-up period of 5.1 years. Primary IORT (IORT at the time of lumpectomy) was performed for 72%, delayed IORT (after lumpectomy) for 3%, intended boost for 8%, and unintended boost (primary IORT followed by whole-breast radiation) for 17% of the patients. At 5 years, IBTR was 6.6% for all the patients, with 8% for the primary IORT cohort and 1.7% for the unintended-boost cohort. No recurrences were identified in the delayed IORT or intended-boost cohorts. Noncompliance with endocrine therapy (ET) was associated with higher IBTR risk (hazard ratio [HR], 3.67). Patients treated with primary IORT who were complaint with ET had a 5-year IBTR rate of 3.9%.

Conclusion: The local recurrence rates in this series differ slightly from recent results of randomized IORT trials and are notably higher than in previous published studies using whole-breast radiotherapy for similar patients with early-stage breast cancer. Understanding differences in this retrospective series and the prospective trials will be critical to optimizing patient selection and outcomes going forward.
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http://dx.doi.org/10.1245/s10434-020-09432-3DOI Listing
May 2021

Evaluation of head and neck soft tissue sarcoma 8th edition pathologic staging system and proposal of a novel stage grouping system.

Oral Oncol 2021 03 8;114:105137. Epub 2021 Jan 8.

Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA; Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, ON, Canada; Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada. Electronic address:

Background: The AJCC 8th edition issued a dedicated staging system for head and neck soft tissue sarcomas (HN-STS) with 2 and 4 cm tumor cut-off points, as well as a T4 classification based on invasion of adjacent structures. Stage groupings were not provided due to a paucity of data.

Methods: We identified HN-STS patients undergoing primary surgery without neoadjuvant therapy patients in the Surveillance, Epidemiology, and End Results (SEER) database. We used multivariable analysis to examine adverse prognosticators. Then, using, recursive partitioning analysis (RPA), we established a stage grouping system that was externally validated in the National Cancer Database (NCDB).

Results: Multivariable analysis in the SEER cohort (N = 546) demonstrated worsened survival with tumors invading adjacent structures (P < 0.001) and increasing de-differentiation (P < 0.001). There was no prognostic difference based on size for T1-3 tumors; however, when assessed as a continuous variable, a 5 cm tumor size cut-off point was predictive of outcome. RPA generated a stage grouping system with the following five-year overall survival: RPA Stage I (pT1-3N0-1G1-2M0) 71.2%, RPA Stage II (pT4abN0-1G1-2M0/pT1-3N0-1G3-4M0) 53.4%, and RPA Stage III (pT4abN0-1G3-4M0) 17.5%. This was successfully externally validated in the NCDB cohort (P < 0.001).

Conclusions: We confirm the importance of structural invasion and grade and demonstrate that the currently used size cut-off points are not prognostic. We propose a novel stage grouping system. A 5 cm tumor size cut-off point for tumor stage should be further evaluated.
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http://dx.doi.org/10.1016/j.oraloncology.2020.105137DOI Listing
March 2021

Outcomes with Partial Breast Irradiation vs. Whole Breast Irradiation: a Meta-Analysis.

Ann Surg Oncol 2021 Sep 3;28(9):4985-4994. Epub 2021 Jan 3.

21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI, USA.

Background: Several randomized trials have been performed comparing partial breast irradiation (PBI) and whole breast irradiation (WBI) though controversy remains, including regarding differences by PBI technique. We performed a meta-analysis to compare results between WBI versus PBI and between PBI techniques.

Methods: A systematic review was performed to identify modern randomized studies listed in MEDLINE from 2005 to 2020. PBI trials were divided into external beam radiation and brachytherapy techniques, with intraoperative radiation excluded. A Bayesian logistic regression model evaluated the risk of ipsilateral breast tumor recurrence (IBTR) and acute and chronic toxicities. The primary outcome was IBTR at 5 years with WBI compared with PBI.

Results: A total of 9758 patients from 7 studies were included (4840-WBI, 4918-PBI). At 5 years, no statistically significant difference in the rate of IBTR was noted between PBI (1.8%, 95% HPD 0.68-3.2%) and WBI (1.7%, 95% HPD 0.92-2.4%). By PBI technique, the 5-year rate of IBTR rate for external beam was 1.7% and 2.2% for brachytherapy. Rates of grade 2 + acute toxicity were 7.1% with PBI versus 47.5% with WBI. For late toxicities, grade 2/3 rates were 0%/0% with PBI compared with 1.0%/0% with WBI.

Conclusions: IBTR rates were similar between PBI and WBI with no significant differences noted by PBI technique; PBI had reduced acute toxicities compared to WBI. Because studies did not provide toxicity data in a consistent fashion, definitive conclusions cannot be made with additional data from randomized trials needed to compare toxicity profiles between PBI techniques.
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http://dx.doi.org/10.1245/s10434-020-09447-wDOI Listing
September 2021

MRI evaluation of solid soft tissue masses of the fingers with pathology correlation.

Eur J Radiol 2021 Feb 5;135:109465. Epub 2020 Dec 5.

Department of Radiology, Northwestern University, Chicago, IL, USA.

Objective: Space occupying lesions of the fingers are commonly encountered in clinical and radiology practice. The objective of this study was to determine the characteristics of these lesions on MRI and to correlate with surgical pathology results.

Material And Methods: This IRB-approved HIPAA-compliant study retrospectively evaluated the clinical, imaging and pathology findings of 100 consecutive patients referred for evaluation of solid soft tissue masses of the fingers. Only solid lesions with MR imaging prior to surgery were included in this study. MR images and when available corresponding radiographs were evaluated by two radiologist in regard to signal characteristics, relation to surrounding structures and enhancement. All masses were classified into different groups based on pathology results.

Results: Tenosynovial giant cell tumor (TSGCT) and fibroma of the tendon sheath were the most common solid tumors (36 %) and malignant tumors represent only 5% of the cohort. 70 % of masses with low T2 signal were TSGCT and fibroma of tendon sheath; 100 % of masses with peripheral high T2 signal and central low T2 signal/thrombus were vascular lesions, representing 41 % of the total vascular lesions in the cohort. Additionally, 100 % of serpiginous/tubular shaped masses were vascular lesions and 67 % of masses with infiltrative borders were malignant masses. Enhancement was important in identifying solid lesions but there was no statistical difference between groups related to enhancement pattern. There was a good agreement for all analyses between both readers.

Conclusion: Typical MR findings can help to narrow the differential diagnosis in the evaluation of finger masses and provide crucial information to guide further management.
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http://dx.doi.org/10.1016/j.ejrad.2020.109465DOI Listing
February 2021
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