Publications by authors named "Mutlay Sayan"

41 Publications

Cost-Effectiveness of Adjuvant Treatment for Ductal Carcinoma In Situ.

J Clin Oncol 2021 Jul 21;39(21):2386-2396. Epub 2021 May 21.

Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT.

Purpose: Ductal carcinoma in situ (DCIS) accounts for 20% of breast cancer cases in the United States and is potentially overtreated, leading to high expenditures and low-value care. We conducted a cost-effectiveness analysis evaluating all adjuvant treatment strategies for DCIS.

Methods: A Markov model was created with six competing treatment strategies: observation, tamoxifen (TAM) alone, aromatase inhibitor (AI) alone, radiation treatment (RT) alone, RT + TAM, and RT + AI. Baseline recurrence rates were modeled using the NSABP B17 and RTOG 9804 trials for standard-risk and good-risk DCIS, respectively. Relative risk reductions and adverse event rates for each treatment strategy were derived from meta-analyses of large randomized trials. We used a willingness-to-pay threshold of $100,000 in US dollars/quality-adjusted life-year and a lifetime horizon for two cohorts of women, age 40 and 60 years. Comprehensive sensitivity analyses evaluated the robustness of base-case results.

Results: RT alone was cost-effective for patients with standard-risk DCIS, and observation was cost-effective for patients with good-risk DCIS, across both age groups. Strategies including TAM or AI resulted in fewer quality-adjusted life-years than observation, because of the prolonged decrement in quality of life outweighing the modest benefit in ipsilateral risk reduction. In sensitivity analysis, RT alone was cost-effective for age 40, good-risk patients when ipsilateral risk reduction matched that of the RTOG 9804 trial, there was minimal increased risk of contralateral breast secondary malignancy, or there was strong patient willingness to pursue RT.

Conclusion: Our findings suggest that cost-effective and clinically optimal treatment strategies are RT alone for standard-risk DCIS and observation for good-risk DCIS, with personalization on the basis of patient age and preference for RT. Hormonal therapy is likely suboptimal for most patients with DCIS.
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http://dx.doi.org/10.1200/JCO.21.00831DOI Listing
July 2021

Comparing the Incidence of Buccal Mucosa Cancer in South Asian, White, and Black Populations Residing in the United States: A Cross-Sectional Analysis.

Asian Pac J Cancer Prev 2021 Jan 1;22(1):195-199. Epub 2021 Jan 1.

Rutgers Cancer Institute of New Jersey, Department of Radiation Oncology, New Brunswick, NJ, USA.

Background: Recreational use of the betel nut, which is common among the South Asian population, is a known risk factor for developing Head and Neck cancer. As South Asians comprise a significant proportion of the United States population, we seek to determine if those living within the country experience a higher rate of head and neck cancers compared to other races.

Methods: Data of patients diagnosed with head & neck cancers from 2010-2016 was collected from the National Cancer Database® and compared to race-matched US census data for each corresponding year to calculate incidence. Pairwise comparisons were performed between the incidence for South Asians versus Whites and South Asians versus Blacks using one sided Chi-square tests.

Results: South Asians experienced a significantly higher incidence of buccal mucosa/vestibule cancers when compared to Whites or Blacks for every year between 2010-2016, but a comparatively lower incidence of larynx or oropharynx cancers.

Conclusions: South Asians residing within the United States have a higher incidence of buccal mucosa/vestibule cancers, but a lower incidence of more common cancers, such as larynx or oropharynx cancer. This may suggest that the etiology behind the high buccal mucosa/vestibule cancer incidence is due to a social habit, as opposed to an inherent racial susceptibility.
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http://dx.doi.org/10.31557/APJCP.2021.22.1.195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184205PMC
January 2021

Hypofractionated Postmastectomy Radiation Therapy.

Adv Radiat Oncol 2021 Jan-Feb;6(1):100618. Epub 2020 Nov 21.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey.

Purpose: To provide an overview of the major randomized trials that support the use of hypofractionated post-mastectomy radiation therapy for locally advanced breast cancer patients.

Methods And Materials: PubMed was systematically reviewed for publications reporting use of of hypofractionated radiation therapy in patients requiring post-mastectomy radiation.

Results: Standard fractionation, which is typically delivered over 5 to 7 weeks, is considered the standard of care in setting of post-mastectomy radiation therapy (PMRT). Modern data has helped to establish hypofractionated whole breast irradiation, which consists of a 3- to 4-week regimen, as a new standard of care for early-stage breast cancer. Hypofractionated whole breast irradiation has also laid the groundwork for the exploration of a hypofractionated approach in the setting of hypofractionated post-mastectomy radiation therapy.

Conclusions: While standard fractionation remains the most commonly utilized regimen for PMRT, recently published trials support the safety and efficacy of a hypofractionated approach. Ongoing trials are further investigating the use of hypofractionated PMRT.
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http://dx.doi.org/10.1016/j.adro.2020.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7809517PMC
November 2020

The clinical impact of removing rectal gas on high-dose-rate brachytherapy dose distributions for gynecologic cancers.

J Appl Clin Med Phys 2021 Feb 13;22(2):35-41. Epub 2021 Jan 13.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA.

Purpose: To evaluate the impact of gas removal on bladder and rectal doses during intracavitary and interstitial high-dose-rate brachytherapy (HDRB) for gynecologic cancers.

Material And Methods: Fifteen patients treated with definitive external beam radiation followed by HDRB for gynecologic cancers for a total of 21 fractions, presented with a significant amount of rectal gas at initial CT imaging (CT ) after implantation. The gas was removed via rectal tubing followed by subsequent scan acquisition (CT ), which was used for planning and treatment delivery. To assess the effect of gas removal on dosimetry, both bladder and rectum volumes were recontoured on CT . In order to evaluate the clinical impact on the total Equivalent-Dose-in-2Gy-fraction (EQD ), each fraction was also replanned to maintain clinically delivered target coverage (HRCTV D90). EQD D2cm for bladder and rectum were compared between plans. The Wilcoxon signed rank test was performed to evaluate statistically significant differences for all comparisons (P < 0.05).

Results: Mean rectum and bladder D , D0.1cm , D1cm , D2cm , and D5cm were significantly different between CT and CT . The mean percent increases on CT for bladder were 12.3, 8.4, 9.9, 10.2, and 9.5% respectively and for rectum were 27.0, 19.6, 18.1, 18.5, and 19.4%, respectively. After replanning with CT to maintain HRCTV D90 EQD , bladder and rectum EQD D2 cm resulted in significantly higher doses. The mean EQD D2 cm difference was 2.4 and 4.1 Gy for bladder and rectum, revealing a higher impact of gas removal on rectal DVH.

Conclusion: Rectal gas removal resulted in statistically significant differences for both bladder and rectum. The resulting larger EQD D2 cm for bladder and rectum demonstrates that if patients were treated without removing gas, target coverage would need to be sacrificed to satisfy the rectum constraints and prevent toxicities. Therefore, this study demonstrates the importance of gas removal for gynecologic HDRB patients.
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http://dx.doi.org/10.1002/acm2.13132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882092PMC
February 2021

Potential Molecular Targets in the Setting of Chemoradiation for Esophageal Malignancies.

J Natl Cancer Inst 2021 Jun;113(6):665-679

Radiation Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Rockville, MD, USA.

Although the development of effective combined chemoradiation regimens for esophageal cancers has resulted in statistically significant survival benefits, the majority of patients treated with curative intent develop locoregional and/or distant relapse. Further improvements in disease control and survival will require the development of individualized therapy based on the knowledge of host and tumor genomics and potentially harnessing the host immune system. Although there are a number of gene targets that are amplified and proteins that are overexpressed in esophageal cancers, attempts to target several of these have not proven successful in unselected patients. Herein, we review our current state of knowledge regarding the molecular pathways implicated in esophageal carcinoma, and the available agents for targeting these pathways that may rationally be combined with standard chemoradiation, with the hope that this commentary will guide future efforts of novel combinations of therapy.
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http://dx.doi.org/10.1093/jnci/djaa195DOI Listing
June 2021

Magnetic Resonance-Guided Radiation Therapy to Boost Cervical Cancer When Brachytherapy Is Not Available: A Case Report.

Adv Radiat Oncol 2020 Sep-Oct;5(5):1066-1070. Epub 2020 Mar 10.

Department of Radiation Oncology, Mehmet Ali Aydınlar Acıbadem University, School of Medicine, Istanbul, Turkey.

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http://dx.doi.org/10.1016/j.adro.2020.02.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557129PMC
March 2020

Risk of symptomatic radiation necrosis in patients treated with stereotactic radiosurgery for brain metastases.

Neurocirugia (Astur : Engl Ed) 2020 Oct 17. Epub 2020 Oct 17.

Department of Radiation Oncology, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey.

Introductio: Stereotactic radiosurgery (SRS) is a treatment option in the initial management of patients with brain metastases. While its efficacy has been demonstrated in several prior studies, treatment-related complications, particularly symptomatic radiation necrosis (RN), remains as an obstacle for wider implementation of this treatment modality. We thus examined risk factors associated with the development of symptomatic RN in patients treated with SRS for brain metastases.

Patients And Methods: We performed a retrospective review of our institutional database to identify patients with brain metastases treated with SRS. Diagnosis of symptomatic RN was determined by appearance on serial MRIs, MR spectroscopy, requirement of therapy, and the development of new neurological complaints without evidence of disease progression.

Results: We identified 323 brain metastases treated with SRS in 170 patients from 2009 to 2018. Thirteen patients (4%) experienced symptomatic RN after treatment of 23 (7%) lesions. After SRS, the median time to symptomatic RN was 8.3 months. Patients with symptomatic RN had a larger mean target volume (p<0.0001), and thus larger V100% (p<0.0001), V50% (p<0.0001), V12Gy (p<0.0001), and V10Gy (p=0.0002), compared to the rest of the cohort. Single-fraction treatment (p=0.0025) and diabetes (p=0.019) were also significantly associated with symptomatic RN.

Conclusion: SRS is an effective treatment option for patients with brain metastases; however, a subset of patients may develop symptomatic RN. We found that patients with larger tumor size, larger plan V100%, V50%, V12Gy, or V10Gy, who received single-fraction SRS, or who had diabetes were all at higher risk of symptomatic RN.
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http://dx.doi.org/10.1016/j.neucir.2020.08.009DOI Listing
October 2020

Patient-Reported Tolerance of Magnetic Resonance-Guided Radiation Therapy.

Front Oncol 2020 21;10:1782. Epub 2020 Sep 21.

Department of Radiation Oncology, School of Medicine, Mehmet Ali Aydınlar Acıbadem University, Istanbul, Turkey.

Purpose: Magnetic resonance-guided radiation therapy (MRgRT) has been incorporated into a growing number of clinical practices world-wide, however, there is limited data on patient experiences with MRgRT. The purpose of this study was to prospectively evaluate patient tolerance of MRgRT using patient reported outcome questionnaires (PRO-Q).

Methods: Ninety patients were enrolled in this prospective observational study and treated with MRgRT (MRIdian Linac System, ViewRay Inc. Oakwood Village, OH, United States) between September 2018 and September 2019. Breath-hold-gated dose delivery with audiovisual feedback was completed as needed. Patients completed an in-house developed PRO-Q after the first and last fraction of MRgRT.

Results: The most commonly treated anatomic sites were the abdomen (47%) and pelvis (33%). Respiratory gating was utilized in 62% of the patients. Patients rated their experience as positive or at least tolerable with mean scores of 1.0-2.8. The most common complaint was the temperature in the room (61%) followed by paresthesias (57%). The degree of anxiety reported by 45% of the patients significantly decreased at the completion of treatment (mean score 1.54 vs. 1.36, = 0.01). Forty-three percent of the patients reported some degree of disturbing noise which was improved considerably by use of music. All patients appreciated their active role during the treatment.

Conclusion: This evaluation of PROs indicates that MRgRT was well-tolerated by our patients. Patients' experience may further improve with adjustment of room temperature and noise reduction.
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http://dx.doi.org/10.3389/fonc.2020.01782DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537416PMC
September 2020

Management of symptomatic radiation necrosis after stereotactic radiosurgery and clinical factors for treatment response.

Radiat Oncol J 2020 Sep 14;38(3):176-180. Epub 2020 Jul 14.

Institute of Health Sciences, Mehmet Ali Aydinlar Acibadem University, Istanbul, Turkey.

Purpose: Approximately 10% of patients who received brain stereotactic radiosurgery (SRS) develop symptomatic radiation necrosis (RN). We sought to determine the effectiveness of treatment options for symptomatic RN, based on patient-reported outcomes.

Materials And Methods: We conducted a retrospective review of 217 patients with 414 brain metastases treated with SRS from 2009 to 2018 at our institution. Symptomatic RN was determined by appearance on serial magnetic resonance images (MRIs), MR spectroscopy, requirement of therapy, and development of new neurological complaints without evidence of disease progression. Therapeutic interventions for symptomatic RN included corticosteroids, bevacizumab and/or surgical resection. Patient-reported therapeutic outcomes were graded as complete response (CR), partial response (PR), and no response.

Results: Twenty-six patients experienced symptomatic RN after treatment of 50 separate lesions. The mean prescription dose was 22 Gy (range, 15 to 30 Gy) in 1 to 5 fractions (median, 1 fraction). Of the 12 patients managed with corticosteroids, 6 patients (50%) reported CR and 4 patients (33%) PR. Of the 6 patients managed with bevacizumab, 3 patients (50%) reported CR and 1 patient (18%) PR. Of the 8 patients treated with surgical resection, all reported CR (100%). Other than surgical resection, age ≥54 years (median, 54 years; range, 35 to 81 years) was associated with CR (odds ratio = 8.40; 95% confidence interval, 1.27-15.39; p = 0.027).

Conclusion: Corticosteroids and bevacizumab are commonly utilized treatment modalities with excellent response rate. Our results suggest that patient's age is associated with response rate and could help guide treatment decisions for unresectable symptomatic RN.
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http://dx.doi.org/10.3857/roj.2020.00171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533401PMC
September 2020

Clinical management of uveal melanoma: a comprehensive review with a treatment algorithm.

Radiat Oncol J 2020 Sep 9;38(3):162-169. Epub 2020 Jul 9.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.

Uveal melanoma (UM), the most frequently occurring non-cutaneous melanoma and most common primary intraocular malignancy in adults, arises from the melanocytes of the choroid in approximately 95% of cases. Prompt diagnosis and treatment is vital as primary tumor size is one of the key factors associated with survival. Despite recent advances in management, more than half of the patients develop metastatic disease which portends poor survival. Currently, treatment options for UM include local resection, enucleation, plaque brachytherapy, and/or particle beam radiotherapy (RT). Enucleation was initially the standard of care in the management of UM, but a shift towards eye-preserving therapeutic choices such as RT and local resection has been noted in recent decades. Plaque brachytherapy, a form of localized RT, is the most popular option and is now the preferred treatment modality for UM. In this review we discuss the etiopathogenesis, clinical presentation and diagnosis of UM and place a special emphasis on therapeutic options. Furthermore, we review the current literature on UM management and propose a functional treatment algorithm for non-metastatic disease.
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http://dx.doi.org/10.3857/roj.2020.00318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533402PMC
September 2020

Adjuvant radiation therapy alone is associated with improved overall survival compared to hormonal therapy alone in older women with estrogen receptor positive early stage breast cancer.

Cancer Med 2020 11 17;9(22):8345-8354. Epub 2020 Sep 17.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.

Background: Breast conserving surgery (BCS) and adjuvant hormonal therapy (HT) without radiation therapy (RT) is an acceptable approach for older women with early stage, estrogen receptor (ER) positive breast cancer. Toxicity and compliance remain issues with HT. Adjuvant RT alone may have better compliance, but its efficacy in the absence of HT is unclear. We aim to assess patterns of adjuvant therapy and survival outcomes among older women with early stage, ER positive (ER+) breast cancer.

Methods: The National Cancer Data Base (NCDB) was used to identify 130,194 women age ≥65 years with invasive ER+, node negative breast cancer diagnosed between 2004 and 2015. All patients underwent BCS. Kaplan-Meier survival curves were used to examine overall survival (OS). The association between adjuvant therapy and OS was assessed in multivariable Cox proportional hazards regression models.

Results: Unadjusted 5/10-year OS rates were 90.0%/64.3% for HT and RT, 84.2%/54.9% for RT alone, 78.7%/44.5% for HT alone, and 71.6%/38.0% for no treatment; p<0.001 for all. Compared to HT alone, the 10-year multivariable hazard ratio (HR) for death for RT alone was 0.86 (95% CI 0.82-0.91). In propensity-matched patients who received RT alone or HT alone (n=21,326), RT alone had significantly better survival at 5 (HR : 0.84) and 10 (HR : 0.87) years.

Conclusions: Older women with early stage ER+ breast cancer who undergo BCS and receive both HT and RT have the best survival, while RT as single-modality therapy had higher rates of OS at 5 and 10 years compared to HT alone.
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http://dx.doi.org/10.1002/cam4.3443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666745PMC
November 2020

Severe Gastrointestinal Mucositis Following Concurrent Palbociclib and Palliative Radiation Therapy.

Anticancer Res 2020 Sep;40(9):5291-5294

Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, U.S.A.

Background/aim: Palbociclib is an FDA-approved cyclin-dependent kinase inhibitor for the treatment of advanced breast cancer. Limited information is available regarding the toxicity of palbociclib and concurrent radiation therapy.

Case Report: Herein, we report a case of esophageal toxicity in a patient treated with palbociclib and radiation therapy. A 63-year-old woman was treated with palbociclib followed by palliative radiation therapy. The patient presented three days after completing radiation therapy with severe odynophagia, and dysphagia and was found to have grade 2-3 esophageal ulcers. Palbociclib and radiation therapy was held on admission, and a resolution of her symptoms and improvement in her oral intake was noted at which time she was restarted on palbociclib with no further radiation treatment.

Conclusion: Caution is advised when patients are undergoing concurrent palbociclib and even low-dose palliative radiation treatment. In these patients, providers should maintain a high index of suspicion for toxicities such as dermatitis or mucositis.
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http://dx.doi.org/10.21873/anticanres.14534DOI Listing
September 2020

New horizons from novel therapies in malignant pleural mesothelioma.

Adv Respir Med 2020 ;88(4):343-351

Department of Radiation Oncology, Acıbadem Maslak Hospital, Istanbul, Turkey.

Malignant pleural mesothelioma (MPM) is a relatively rare, but highly lethal cancer of the pleural mesothelial cells. Its pathoge-nesis is integrally linked to asbestos exposure. In spite of recent developments providing a more detailed understanding of the pathogenesis, the outcomes continue to be poor. To date, trimodality therapy involving surgery coupled with chemotherapy and/or radiotherapy remains the standard of therapy. The development of resistance of the tumor cells to radiation and several che-motherapeutic agents poses even greater challenges in the management of this cancer. Ionizing radiation damages cancer cell DNA and aids in therapeutic response, but it also activates cell survival signaling pathways that helps the tumor cells to overcome radiation-induced cytotoxicity. A careful evaluation of the biology involved in mesothelioma with an emphasis on the workings of pro-survival signaling pathways might offer some guidance for treatment options. This review focuses on the existing treatment options for MPM, novel treatment approaches based on recent studies combining the use of inhibitors which target different pro-survival pathways, and radiotherapy to optimize treatment.
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http://dx.doi.org/10.5603/ARM.a2020.0103DOI Listing
June 2021

Prevalence of Surface Contamination With SARS-CoV-2 in a Radiation Oncology Clinic.

JAMA Oncol 2020 10;6(10):1632-1634

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick.

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http://dx.doi.org/10.1001/jamaoncol.2020.3552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453342PMC
October 2020

Comparison of kV Orthogonal Radiographs and kV-Cone-Beam Computed Tomography Image-Guided Radiotherapy Methods With and Without Implanted Fiducials in Prostate Cancer.

Cureus 2020 Aug 21;12(8):e9916. Epub 2020 Aug 21.

Radiation Oncology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, TUR.

Introduction The aim of this study is to investigate the performance of kilovoltage (kV) cone-beam computed tomography (CBCT)-based adjustments with respect to kV-orthogonal fiducial marker-based matching in a group of patients with prostate cancer.  Methods Twenty prostate cancer patients were evaluated retrospectively: 10 with implanted fiducial markers and 10 without. Daily orthogonal kV imaging was recorded prior to radiation delivery. Images were evaluated in the left-right (LR), anterior-posterior (AP), and superior-inferior (SI) directions by matching either the implanted fiducials or going off bony anatomy, depending on the presence or absence of markers, respectively. Cone-beam computed tomography (CBCT) imaging was also subsequently acquired and images were aligned with the planning CT. The couch shifts were calculated and the patient's position was adjusted accordingly. Standard deviations and random errors were also computed. Pearson correlation and Bland-Altman analysis were performed to evaluate relationships between the datasets. Results A total of 240 images were evaluated. The Pearson correlation coefficient for shifts applied to patients with markers using kV and CBCT was 88.3%, 87.8%, and 94.5% for the LR, AP, and SI directions, respectively. For those without markers, the respective values for the LR, AP, and SI directions were: 39.3%, 22.4%, and 3.7%. A Bland-Altman analysis comparing kV and CBCT in patients with markers, revealed R values of 0.152, 0.282, and 0.097 in the LR, AP, and SI directions, respectively. The R values for patients without markers were 0.008, 0.01, and 0.057, in the LR, AP, and SI directions, respectively. Conclusions Our data suggest that CBCT can be a viable option for image-guidance in clinical settings where fiducial markers are unavailable such as situations of inaccessibility or medical contraindications.
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http://dx.doi.org/10.7759/cureus.9916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445001PMC
August 2020

Utilization of Hypofractionated Whole-Breast Radiotherapy With Concurrent Anti-Human Epidermal Growth Factor Receptor 2 (HER2) Therapy.

Clin Breast Cancer 2021 02 29;21(1):31-36. Epub 2020 Jun 29.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ. Electronic address:

Introduction: Hypofractionated radiotherapy (Hypo-RT) is now considered the standard of care for the majority of patients receiving whole-breast irradiation (WBI). However, there are few data on the use of Hypo-RT in human epidermal growth factor receptor 2 (HER2)-positive patients receiving concurrent anti-HER2 therapy. In this study, we sought to examine patterns of WBI in HER2-positive patients.

Patients And Methods: Using the National Cancer Data Base, we identified women with nonmetastatic HER2-positive breast cancer diagnosed between 2010 and 2015 who received WBI. The Hypo-RT group was defined as those receiving 21 or fewer fractions. All other patients were in the conventional radiotherapy (RT) group. Multivariate logistic regression was used to identify predictors of Hypo-RT utilization. Five-year overall survival was estimated by the Kaplan-Meier method.

Results: The study included 15,776 patients, of whom 17.7% received Hypo-RT. The rate of Hypo-RT utilization increased from 7.4% in 2010 to 29.3% in 2015 (P = .004). Predictors of Hypo-RT use included older age (≥60 vs. < 60 years), higher median income quartile, further distance from the treatment facility (>50 vs. ≤50 miles), treatment at an academic facility, and later year of diagnosis. Unadjusted 5-year overall survival rates were similar among patients who received Hypo-RT and conventional RT (93.9% vs. 95.2%, P = .26). After adjusting for patient, facility, and tumor variables, Hypo-RT was not significantly associated with survival.

Conclusion: Although Hypo-RT was not commonly delivered in patients with HER2-positive breast cancer, the utilization rate quadrupled over the study period. Multiple socioeconomic and clinical predictors of Hypo-RT receipt were identified. Adjuvant RT regimen was not significantly associated with overall survival.
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http://dx.doi.org/10.1016/j.clbc.2020.06.007DOI Listing
February 2021

The Impact of Everolimus and Radiation Therapy on Pulmonary Fibrosis.

Medicina (Kaunas) 2020 Jul 13;56(7). Epub 2020 Jul 13.

Department of Radiation Oncology, Medicine Faculty, Acibadem University, 34457 Istanbul, Turkey.

Everolimus (EVE) is a mammalian target of the rapamycin (mTOR) inhibitor that is widely used in cancer patients. Pulmonary toxicity, usually manifesting as interstitial pneumonitis, is a serious adverse effect of this drug. Radiation therapy, which is often administered in conjunction with chemotherapy for synergistic effects, also causes pulmonary fibrosis. In view of pulmonary damage development in these two forms of cancer treatment, we have examined the effect of EVE administration individually, in combination with radiation given in varying sequences, and its relation to the extent of pulmonary damage. We performed an experimental study in albino rats, which were randomized into five groups: (1) control group, (2) EVE alone, (3) EVE 22 h after radiation, (4) EVE 2 h after irradiation, and (5) only radiation. Sixteen weeks after thoracic irradiation, rat lung tissue samples were examined under light microscopy, and the extent of pulmonary damage was estimated. After this, we calculated median fibrosis scores in each group. The highest fibrosis score was noted in Group 4. Among the five groups, the control group had a significantly lower median fibrosis score compared to the others. When the median fibrosis score of the group that received concurrent EVE with radiation therapy (RT) (Group 4) was compared with that of the control group, the difference was statistically significant ( = 0.0022). However, no significant differences were achieved among the study groups that received EVE only or RT only, whether concurrently or sequentially ( > 0.05). EVE is an effective treatment option for the management of several malignancies and is often combined with other therapies, such as radiation, for a more efficient response. However, an increased risk of pulmonary fibrosis should also be anticipated when these two modalities are combined, as they both can cause pulmonary damage, especially when administered concurrently.
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http://dx.doi.org/10.3390/medicina56070348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404687PMC
July 2020

Evaluation of response to stereotactic radiosurgery in patients with radioresistant brain metastases.

Radiat Oncol J 2019 Dec 31;37(4):265-270. Epub 2019 Dec 31.

Department of Radiation Oncology, School of Medicine, Mehmet Ali Aydinlar Acibadem University, Istanbul, Turkey.

Purpose: Renal cell carcinoma (RCC) and melanoma have been considered 'radioresistant' due to the fact that they do not respond to conventionally fractionated radiation therapy. Stereotactic radiosurgery (SRS) provides high-dose radiation to a defined target volume and a limited number of studies have suggested the potential effectiveness of SRS in radioresistant histologies. We sought to determine the effectiveness of SRS for the treatment of patients with radioresistant brain metastases.

Materials And Methods: We performed a retrospective review of our institutional database to identify patients with RCC or melanoma brain metastases treated with SRS. Treatment response were determined in accordance with the Response Evaluation Criteria in Solid Tumors.

Results: We identified 53 radioresistant brain metastases (28% RCC and 72% melanoma) treated in 18 patients. The mean target volume and coverage was 6.2 ± 9.5 mL and 95.5% ± 2.9%, respectively. The mean prescription dose was 20 ± 4.9 Gy. Forty lesions (75%) demonstrated a complete/partial response and 13 lesions (24%) with progressive/stable disease. Smaller target volume (p < 0.001), larger SRS dose (p < 0.001), and coverage (p = 0.008) were found to be positive predictors of complete response to SRS.

Conclusion: SRS is an effective management option with up to 75% response rate for radioresistant brain metastases. Tumor volume and radiation dose are predictors of response and can be used to guide the decision-making for patients with radioresistant brain metastases.
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http://dx.doi.org/10.3857/roj.2019.00409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952719PMC
December 2019

Daily localization of partial breast irradiation patients with three-dimensional ultrasound imaging.

Radiat Oncol J 2019 Dec 31;37(4):259-264. Epub 2019 Dec 31.

Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA.

Purpose: Accurate localization of the lumpectomy cavity during accelerated partial breast radiation (APBR) is essential for daily setup to ensure the prescribed dose encompasses the target and avoids unnecessary irradiation to surrounding normal tissues. Three-dimensional ultrasound (3D-US) allows direct visualization of the lumpectomy cavity without additional radiation exposure. The purpose of this study was to evaluate the feasibility of 3D-US in daily target localization for APBR.

Materials And Methods: Forty-seven patients with stage I breast cancer who underwent breast conserving surgery were treated with a 2-week course of APBR. Patients with visible lumpectomy cavities on high quality 3D-US images were included in this analysis. Prior to each treatment, X-ray and 3D-US images were acquired and compared to images from simulation to confirm accurate position and determine shifts. Volume change of the lumpectomy cavity was determined daily with 3D-US.

Results: A total of 118 images of each modality from 12 eligible patients were analyzed. The average change in cavity volume was 7.8% (range, -24.1% to 14.4%) on 3D-US from simulation to the end-of-treatment. Based on 3D-US, significantly larger shifts were necessary compared to portal films in all three dimensions: anterior/posterior (p = 7E-11), left/right (p = 0.002), and superior/inferior (p = 0.004).

Conclusion: Given that the lumpectomy cavity is not directly visible via X-ray images, accurate positioning may not be fully achieved by X-ray images. Therefore, when the lumpectomy cavity is visible on US, 3D-US can be considered as an alternative to X-ray imaging during daily positioning for selected patients treated with APBR, thus avoiding additional exposure to ionizing radiation.
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http://dx.doi.org/10.3857/roj.2019.00052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6952713PMC
December 2019

The Impact of Formal Mentorship Programs on Mentorship Experience Among Radiation Oncology Residents From the Northeast.

Front Oncol 2019 4;9:1369. Epub 2019 Dec 4.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States.

Strong mentorship has been shown to improve mentee productivity, clinical skills, medical knowledge, and career preparation. We conducted a survey to evaluate resident satisfaction with mentorship within their radiation oncology residency programs. In January 2019, 126 radiation oncology residents training at programs in the northeastern United States were asked to anonymously complete the validated Munich Evaluation of Mentoring Questionnaire (MEMeQ). Results of residents with a formal mentoring program were compared to those without a formal program. Overall response rate was 42%( = 53). Participants were 25% post-graduate year two (PGY-2), 21% PGY-3, 26% PGY-4, and 28% PGY-5. Only 38% of residents reported participation in a formal mentoring program, while 62% had no formal program, and 13% reported having no mentor at all. Residents participating in a formal mentoring program reported strikingly higher rates of overall satisfaction with mentoring compared to those who were not (90% vs. 9%, < 0.001). Overall, 38% of residents were either satisfied/very satisfied with their mentoring experience, while 49% of residents were unsatisfied/very unsatisfied. Residents participating in a formal mentorship program are significantly more likely to be satisfied with their mentoring experience than those who are not. Our results suggest that radiation oncology residency programs should strongly consider implementing formal mentorship programs.
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http://dx.doi.org/10.3389/fonc.2019.01369DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6904328PMC
December 2019

Current treatment strategies in malignant pleural mesothelioma with a treatment algorithm.

Adv Respir Med 2019 ;87(5):289-297

Department of Radiation Oncology, Mehmet Ali Aydınlar Acıbadem University, School of Medicine, Istanbul, Turkey.

Malignant pleural mesothelioma (MPM) is arare disease with apoor prognosis. The main therapeutic options for MPM include surgery, chemotherapy, and radiation therapy (RT). Although multimodality therapy has been reported to improve survival, not every medically operable patient is able to undergo all recommended therapy. With improvements in surgical techniques and systemic therapies, as well as advancements in RT, there has been apotential new paradigm in the management of this disease. In this review, we discuss the current literature on MPM management and propose afunctional treatment algorithm.
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http://dx.doi.org/10.5603/ARM.2019.0051DOI Listing
April 2020

Acute Cardiotoxicity With Concurrent Trastuzumab and Hypofractionated Radiation Therapy in Breast Cancer Patients.

Front Oncol 2019 1;9:970. Epub 2019 Oct 1.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States.

Radiotherapy for patients with non-metastatic human epidermal growth factor receptor 2 (HER2) positive breast cancer is commonly administered concurrently with adjuvant trastuzumab. However, there is limited data on the use of concurrent trastuzumab and hypofractionated radiotherapy (Hypo-RT), which is now standard of care for the majority of women receiving whole breast irradiation. In this study, we compared acute cardiotoxicity rates in HER2-positive breast cancer patients treated with concurrent trastuzumab and Hypo-RT or conventionally fractionated radiotherapy (Conv-RT). We performed a review of our institutional database to identify HER2-positive breast cancer patients treated with trastuzumab and Hypo-RT or Conv-RT from 2005 to 2018 who underwent serial cardiac Left Ventricular Ejection Fraction (LVEF) evaluation. Decrease in LVEF was assessed by either echocardiography (ECHO) or multiple gated acquisition (MUGA) scan performed at baseline and every 3 months during trastuzumab therapy. Significant LVEF decline was defined as an absolute decrease in LVEF of ≥10% below the lower limit of normal or ≥16% from baseline value. We identified 41 patients treated with Hypo-RT and 100 patients treated with Conv-RT. Median follow-up was 32 months (range, 13-90 months). Baseline median LVEF was 62% (range, 50-81%) in Hypo-RT group and 64% (range, 51-76%) in Conv-RT group ( = 0.893). Final median LVEF was 60% (range, 50-75%) in both groups. Three patients (7%) in Hypo-RT and five (5%) in Conv-RT group developed significant asymptomatic LVEF decline ( = 0.203). There was no significant difference in mean heart dose in patients who developed significant asymptomatic LVEF decline vs. those who did not in Hypo-RT ( = 0.427) and Conv-RT ( = 0.354) groups. No symptomatic congestive heart failure was reported in either group. The rate of asymptomatic LVEF decline in patients receiving concurrent trastuzumab and Hypo-RT was low (7%) and was similar to the rate observed in patients receiving Conv-RT. Longer follow-up is warranted to assess late cardiotoxicity.
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http://dx.doi.org/10.3389/fonc.2019.00970DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6779787PMC
October 2019

Synchronous Oligometastatic Non-small Cell Lung Cancer Managed With Curative-Intent Chemoradiation Therapy: Long-term Outcomes From a Single Institution.

Adv Radiat Oncol 2019 Jul-Sep;4(3):541-550. Epub 2019 Mar 22.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey.

Purpose: We examined long-term clinical outcomes among patients with synchronous oligometastatic non-small cell lung cancer (NSCLC) treated at our institution with definitive thoracic chemoradiation therapy (CRT) and local therapy to all oligometastatic lesions.

Methods And Materials: A retrospective review identified 38 patients with synchronous oligometastatic NSCLC (≤3 metastatic lesions) who were treated with definitive CRT to the primary tumor and regional lymph nodes between 1999 and 2017 at our institution. Of the 38 patients, 27 patients (71%) received induction chemotherapy, all of whom responded or stabilized with initial systemic therapy before consideration of CRT. Most patients received chemotherapy concurrently with radiation therapy (n = 32; 84%) and local therapy to the metastatic disease site(s) (n = 34; 89%). We assessed patterns of progression or failure, overall survival (OS), progression-free survival (PFS), and toxicities.

Results: The median follow-up duration was 54.9 months. Most patients (84%) presented with N2 to N3 disease. The brain or central nervous system was the most common site of disease progression and occurred in 16 of 28 patients (57%) experiencing any progression and 10 of 16 patients (63%) who initially presented with brain oligometastases. Median OS was 21.1 months (95% confidence interval [CI], 15.6-49.0 months), and median PFS 9.7 months (95% CI, 8.2-14.4 months). The 1-, 2-, and 4-year OS rates were 75.7%, 45.0%, and 33.7%, respectively. On multivariate analysis, both locoregional progression (hazard ratio: 5.8; 95% CI, 2.2-15.0;  = .0003) and distant progression (hazard ratio: 6.0; 95% CI, 2.3-15.4;  = .0002), when treated as time-dependent covariates, were associated with inferior OS. Grade ≥3 esophagitis occurred in 9% and grade ≥3 pneumonitis in 5% of patients with evaluable data.

Conclusions: Patients with synchronous oligometastatic NSCLC and a high regional nodal burden treated with definitive thoracic CRT experienced favorable survival outcomes and low toxicity. At our institution, treating oligometastatic disease with CRT after systemic therapy is incorporated into the treatment plan from the onset of therapy, and we monitor the neuraxis closely for progression during and after treatment. Future research should focus on novel treatment combinations, such as immunotherapy or targeted systemic therapy as appropriate to further improve tumor control and survival.
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http://dx.doi.org/10.1016/j.adro.2019.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6639751PMC
March 2019

Rethinking the Role of Radiation Therapy in the Treatment of Unresectable Hepatocellular Carcinoma: A Data Driven Treatment Algorithm for Optimizing Outcomes.

Front Oncol 2019 18;9:345. Epub 2019 Jun 18.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States.

Hepatocellular carcinoma (HCC) is the second most common cause of cancer death worldwide, with a majority of HCC patients not suitable for curative therapies. Approximately 70% of initially diagnosed patients cannot undergo surgical resection or transplantation due to locally advanced disease, poor liver function/underlying cirrhosis, or additional comorbidities. Local therapeutic options for patients with unresectable HCC, who are not suitable for thermal ablation, include transarterial embolization (bland, chemoembolization, radioembolization) and/or external beam radiation therapy (EBRT). Regarding EBRT specifically, technological advancements provide a means for safe and effective radiotherapy delivery in a wide spectrum of HCC patients. In multiple prospective studies, EBRT delivery in a variety of different fractionation schemes or in combination with transcatheter arterial chemoembolization (TACE) demonstrate improved outcomes, particularly with combination therapy. The Barcelona Clinic Liver Cancer classification provides a framework for treatment selection; however, given the growing complexity of treatment strategies, this classification system tends to simplify decision-making. In this review, we discuss the current literature regarding unresectable HCC and propose a modified treatment algorithm that emphasizes the role of radiation therapy for Child-Pugh score A or B patients with ≤3 nodules measuring >3 cm, multinodular disease or portal venous thrombosis.
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http://dx.doi.org/10.3389/fonc.2019.00345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6591511PMC
June 2019

Vertebral body irradiation during chemoradiation therapy for esophageal cancer contributes to acute bone marrow toxicity.

J Gastrointest Oncol 2019 Jun;10(3):513-522

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA.

Background: Hematologic toxicity (HT) commonly occurs during chemoradiation therapy (CRT) for esophageal cancer. We sought to determine radiation doses that correlate with declines in blood counts due to vertebral body (VB) irradiation during CRT.

Methods: We analyzed 53 esophageal cancer patients who were treated with weekly neoadjuvant carboplatin, paclitaxel and RT with weekly complete blood counts (CBC) available during treatment. HTs were graded according to the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0). Dose volume histogram (DVH) parameters of Vx, defined as percentage of entire bony vertebra (body, pedicles, laminae, processes) receiving at least x Gy of radiation, were collected for VB V (VBV), VBV-VBV in increments of 10, and mean vertebral dose (MVD). Linear and logistic regressions were performed to identify associations between leukopenia nadirs and DVH parameters. Receiver operator curves identified thresholds to avoid grade ≥3 leukopenia.

Results: A proportion of 32.1% of patients (n=17) developed grade 3 leukopenia and 5.7% (n=3) developed grade 4 leukopenia. VBV, VBV, VBV, VBV, and MVD were significantly associated with worsening leukopenia on univariate and multivariate analysis. Associations with leukopenia were not seen with VBV and VBV DVH values. Thresholds to avoid grade ≥3 leukopenia were VBV <49.1%, VBV <45.6%, and MVD <17.2 Gy.

Conclusions: VBV, VBV, VBV, VBV associate with leukopenia during CRT for esophageal cancer patients. Improved radiation sparing of the VB may decrease HT and may improve tolerability of concurrent chemotherapy and allow for intensification of systemic therapy during RT.
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http://dx.doi.org/10.21037/jgo.2019.01.20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534715PMC
June 2019

5-Year Results of a Prospective Phase 2 Trial Evaluating 3-Week Hypofractionated Whole Breast Radiation Therapy Inclusive of a Sequential Boost.

Int J Radiat Oncol Biol Phys 2019 10 5;105(2):267-274. Epub 2019 Jun 5.

Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey. Electronic address:

Purpose: To report 5-year outcomes of a phase 2 trial of hypofractionated whole breast irradiation (HF-WBI) completed in 3 weeks, inclusive of a sequential boost.

Methods And Materials: Women with stage 0-IIIA breast cancer (ductal carcinoma in situ through T2N2a) were enrolled on a prospective, phase 2 trial of accelerated HF-WBI. We delivered a whole breast dose of 36.63 Gy in 11 fractions of 3.33 Gy, with an equivalent dose to the regional nodes when indicated, followed by a tumor bed boost of 13.32 Gy in 4 fractions of 3.33 Gy over a total of 15 treatment days. The primary endpoint was locoregional control; secondary endpoints included acute/late toxicity and physician-assessed and patient-reported breast cosmesis.

Results: Between 2009 and 2017, we enrolled 150 patients, of whom 146 received the protocol treatment. Median age was 54 years (range, 33-82) and median follow-up was 62 months. Patients with higher-risk disease comprised 59% of the cohort, including features such as young age (33% ≤50 years), positive nodes (13%), triple-negative disease (11%), and treatment with regional nodal irradiation (11%) and/or neoadjuvant/adjuvant chemotherapy (36%). Five-year estimated locoregional and distant control were 97.7% (95% confidence interval [CI], 93.0%-99.3%) and 97.9% (95% CI, 93.6%-99.3%), respectively. Five-year breast cancer-specific and overall survival were 99.2% (95% CI, 94.6%-99.9%) and 97.3% (95% CI, 91.9%-99.1%), respectively. Acute/late grade 2 and 3 toxicities were observed in 30%/10% and 1%/3% of patients, respectively. There were no grade 4 or 5 toxicities. Physicians assessed breast cosmesis as good or excellent in 95% of patients; 85% of patients self-reported slight to no difference between the treated and untreated breast.

Conclusions: Our phase 2 trial offers one of the shortest courses of HF-WBI; at 5 years of follow-up there continues to be excellent locoregional control and low toxicity with favorable cosmetic outcomes in a heterogeneous cohort of patients.
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http://dx.doi.org/10.1016/j.ijrobp.2019.05.063DOI Listing
October 2019

Multiple primary malignancies in patients with anal squamous cell carcinoma.

J Gastrointest Oncol 2018 Oct;9(5):853-857

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA.

Prior studies examining the risk of second primary malignancy (SPM) after a first primary cancer generally have used large datasets such as the Surveillance, Epidemiology, and End Results (SEER) registry and excluded survivors of previous primaries and developers of synchronous primaries. The goal of this study was to provide a more complete representation of multiple cancer risk in squamous cell carcinoma of the anus (SCCA) patients. A single-institution retrospective study of 46 patients treated definitively for SCCA between January 2006 and July 2017 was conducted. Of the 46 patients, 18 (39%) had either a primary malignancy before SCCA (n=9) or SPM after an index SCCA (n=9). Six patients had ≥3 total malignancies. In our cohort, patients without SPMs tended to die from SCCA recurrence, while patients with SPMs were more likely to die from their SPM than from SCCA. Our study suggests that patients with SCCA are often either survivors of previous cancers or develop later malignancies. Several risk factors may play a role including HPV infection, HPV-related or treatment-related immunosuppression, somatic mutations due to chemotherapy, and genetic factors. Patients with SCCA require lifelong surveillance given their elevated risk of malignancy. Future work should focus on identifying genomic or immunologic factors that may predispose SCCA patients to develop multiple primary malignancies.
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http://dx.doi.org/10.21037/jgo.2018.06.07DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6219985PMC
October 2018

Dosimetric Predictors of Symptomatic Cardiac Events After Conventional-Dose Chemoradiation Therapy for Inoperable NSCLC.

J Thorac Oncol 2018 10 5;13(10):1508-1518. Epub 2018 Jun 5.

Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey. Electronic address:

Introduction: We hypothesized that higher cardiac doses correlates with clinically significant cardiotoxicity after standard-dose chemoradiation therapy (CRT) (∼60 Gy) for inoperable NSCLC.

Methods: We retrospectively reviewed the records of 140 patients with inoperable NSCLC treated with concurrent CRT from 2007 to 2015. Extracted data included baseline cardiac status, dosimetric parameters to the whole heart (WH) and cardiac substructures, and the development of post-CRT symptomatic cardiac events (acute coronary syndrome [ACS], arrhythmia, pericardial effusion, pericarditis, and congestive heart failure [CHF]). Competing risks analysis was used to estimate time to cardiac events.

Results: Median follow-up was 47.4 months. Median radiation therapy dose was 61.2 Gy (interquartile range, 60 to 66 Gy). Forty patients (28.6%) developed 47 symptomatic cardiac events at a median of 15.3 months to first event. On multivariate analysis, higher WH doses and baseline cardiac status were associated with an increased risk of symptomatic cardiac events. The 4-year cumulative incidence of symptomatic cardiac events was 48.6% versus 18.5% for mean WH dose ≥ 20 Gy versus < 20 Gy, respectively (p = 0.0002). Doses to the WH, ventricles, and left anterior descending artery were associated with ACS/CHF, whereas doses to the WH and atria were not associated with supraventricular arrhythmias. Symptomatic cardiac events (p = 0.0001) were independently associated with death.

Conclusions: Incidental cardiac irradiation was associated with subsequent symptomatic cardiac events, particularly ACS/CHF, and symptomatic cardiac events were associated with inferior survival. These results support the minimization of cardiac doses among patients with inoperable NSCLC receiving standard-dose CRT.
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http://dx.doi.org/10.1016/j.jtho.2018.05.028DOI Listing
October 2018

Long-term cosmesis following a novel schedule of accelerated partial breast radiation in selected early stage breast cancer: result of a prospective clinical trial.

Radiat Oncol J 2017 Dec 15;35(4):325-331. Epub 2017 Dec 15.

Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA.

Purpose: There is controversy regarding the cosmetic outcome after accelerated partial breast radiation (APBR). We report the cosmetic outcome from a single-arm prospective clinical trial of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I breast cancer (BC), using a novel fractionation schedule.

Materials And Methods: Forty-two patients aged ≥65, with Stage I BC who underwent breast-conserving surgery were enrolled in a phase I/II study evaluating a 2-week course of APBR. Thirty eligible patients received 40 Gy in 4 Gy daily fractions. Cosmetic outcome was assessed subjectively by physician/patient and objectively by using a computer program (BCCT.core) before APBR, during, and after completion of the treatment.

Results: The median age was 72 years, the median tumor size was 0.8 cm, and the median follow-up was 50.5 months. The 5-year locoregional control in this cohort was 97% and overall survival 87%. At the last follow-up, patients and physicians rated cosmesis as 'excellent' or 'good' in 100% and 91 %, respectively. The BCCT.core program scored the cosmesis as 'excellent' or 'good' in 87% of the patients at baseline and 81% at the last follow-up. The median V50 (20 Gy) of the whole breast volume (WBV) was 37.2%, with the median WBV V100 (40 Gy) of 10.9%.

Conclusion: An excellent rate of tumor control was observed in this prospective trial. By using multiple assessment techniques, we are showing acceptable cosmesis, supporting the use of IMRT planned APBR with daily schedule in elderly patients with early stage BC.
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http://dx.doi.org/10.3857/roj.2017.00171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5769880PMC
December 2017

A novel schedule of accelerated partial breast radiation using intensity-modulated radiation therapy in elderly patients: survival and toxicity analysis of a prospective clinical trial.

Radiat Oncol J 2017 Mar 13;35(1):32-38. Epub 2017 Feb 13.

Department of Radiation Oncology, University of Vermont Medical Center, Burlington, VT, USA.

Purpose: Several accelerated partial breast radiation (APBR) techniques have been investigated in patients with early-stage breast cancer (BC); however, the optimal treatment delivery techniques remain unclear. We evaluated the feasibility and toxicity of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I BC, using a novel fractionation schedule.

Materials And Methods: Forty-two patients aged ≥65 years, with stage I BC who underwent breast conserving surgery were enrolled in a phase I/II study evaluating APBR using IMRT. Forty eligible patients received 40 Gy in 4 Gy daily fractions. Patients were assessed for treatment related toxicities, and cosmesis, before APBR, during, and after completion of the treatment.

Results: The median age was 73 years, median tumor size 0.8 cm and the median follow-up was 54 months. The 5-year locoregional control was 97.5% and overall survival 90%. Erythema and skin pigmentation was the most common acute adverse event, reported by 27 patients (69%). Twenty-six patients (65%) reported mild pain, rated 1-4/10. This improved at last follow-up to only 2 (15%). Overall the patient and physician reported worst late toxicities were lower than the baseline and at last follow-up, patients and physicians rated cosmesis as excellent/good in 93% and 86 %, respectively.

Conclusion: In this prospective trial, we observed an excellent rate of tumor control with daily APBR. The acceptable toxicity profile and cosmetic results of this study support the use of IMRT planned APBR with daily schedule in elderly patients with early stage BC.
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http://dx.doi.org/10.3857/roj.2016.01963DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398344PMC
March 2017