Publications by authors named "Randa Tao"

42 Publications

The Effect of Measured Radiotherapy Dose on Intrathecal Drug Delivery System Function.

Neuromodulation 2021 Feb 23. Epub 2021 Feb 23.

Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.

Objectives: Radiation therapy (RT) and intrathecal drug delivery systems (IDDS) are often used concurrently to optimize pain management in patients with cancer. Concern remains among clinicians regarding the potential for IDDS malfunction in the setting of RT. Here we assessed the frequency of IDDS malfunction in a large cohort of patients treated with RT.

Materials And Methods: Cancer patients with IDDS and subsequent RT at our institution from 2011 to 2019 were eligible for this study. Patients were excluded in the rare event that their IDDS was managed by an outside clinic and follow-up documentation was unavailable. Eighty-eight patients aged 22-88 years old (43% female, 57% male) representing 106 separate courses of RT were retrospectively identified. Patients received varying levels of radiation for treatment of cancer and cumulative dose to the IDDS was calculated. IDDS interrogation was subsequently performed by a pain specialist. Malfunction was recorded as deviation from the expected drug volume and/or device errors reported upon interrogation as defined by the manufacturer.

Results: Total measured RT dose to the IDDS ranged from 0 to 18.0 Gy (median = 0.2 Gy) with median dose of 0.04 Gy/fraction (range, 0-3.2 Gy/fraction). Ten pumps received a total dose >2 Gy and three received ≥5 Gy. Eighty-two percentage of patients had follow-up with a pain specialist for IDDS interrogation and all patients underwent follow-up with a healthcare provider following RT. There were zero incidences of IDDS malfunction related to RT. No patient had clinical evidence of radiation related pump malfunction at subsequent encounters.

Conclusions: We found no evidence that RT in patients with IDDS led to device failure or dysfunction. While radiation oncologists and pain specialists should coordinate patient care, it does not appear that RT dose impacts the function of the IDDS to warrant significant clinical concern.
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http://dx.doi.org/10.1111/ner.13372DOI Listing
February 2021

Erratum: "Preliminary clinical experience with Calypso anchored beacons for tumor tracking in lung SBRT" [Med. Phys. (2020)].

Med Phys 2021 Jan 28;48(1):533. Epub 2020 Jul 28.

Department of Radiation Oncology, University of Utah, Salt Lake City, UT, 84112, USA.

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http://dx.doi.org/10.1002/mp.14376DOI Listing
January 2021

Radiation therapy and secondary malignancy in Li-Fraumeni syndrome: A hereditary cancer registry study.

Cancer Med 2020 Nov 15;9(21):7954-7963. Epub 2020 Sep 15.

Department of Radiation Oncology, University of Utah- Huntsman Cancer Institute, Salt Lake City, UT, USA.

Background: Li-Fraumeni Syndrome (LFS) is a rare cancer-predisposing condition caused by germline mutations in TP53. Conventional wisdom and prior work has implied an increased risk of secondary malignancy in LFS patients treated with radiation therapy (RT); however, this risk is not well-characterized. Here we describe the risk of subsequent malignancy and cancer-related death in LFS patients after undergoing RT for a first or second primary cancer.

Methods: We reviewed a multi-institutional hereditary cancer registry of patients with germline TP53 mutations who were treated from 2004 to 2017. We assessed the rate of subsequent malignancy and death in the patients who received RT (RT group) as part of their cancer treatment compared to those who did not (non-RT group).

Results: Forty patients with LFS were identified and 14 received RT with curative intent as part of their cancer treatment. The median time to follow-up after RT was 4.5 years. Fifty percent (7/14) of patients in the curative-intent group developed a subsequent malignancy (median time 3.5 years) compared to 46% of patients in the non-RT group (median time 5.0 years). Four of seven subsequent malignancies occurred within a prior radiation field and all shared histology with the primary cancer suggesting recurrence rather than new malignancy.

Conclusion: We found that four of14 patients treated with RT developed in-field malignancies. All had the same histology as the primary suggesting local recurrences rather than RT-induced malignancies. We recommend that RT should be considered as part of the treatment algorithm when clinically indicated and after multidisciplinary discussion.
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http://dx.doi.org/10.1002/cam4.3427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643676PMC
November 2020

ASO Author Reflections: The Impact of Local Therapy on Non-metastatic Esophageal Cancer.

Ann Surg Oncol 2020 Dec 13;27(Suppl 3):818-819. Epub 2020 Jul 13.

Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, USA.

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http://dx.doi.org/10.1245/s10434-020-08808-9DOI Listing
December 2020

Refusal of Local Therapy in Esophageal Cancer and Impact on Overall Survival.

Ann Surg Oncol 2021 Feb 9;28(2):663-675. Epub 2020 Jul 9.

Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.

Objective: The aim of this study was to understand factors associated with refusal of local therapy in esophageal cancer and compare the overall survival (OS) of patients who refuse therapies with those who undergo recommended treatment.

Methods: National Cancer Database data for patients with non-metastatic esophageal cancer from 2006 to 2013 were pooled. T1N0M0 tumors were excluded. Pearson's Chi-square test and multivariate logistic regression analyses were used to assess demographic, clinical, and treatment factors. After propensity-score matching with inverse probability of treatment weighting, OS was compared between patients who refused therapies and those who underwent recommended therapy, using Kaplan-Meier analyses and doubly robust estimation with multivariate Cox proportional hazards modeling.

Results: In total, 37,618 patients were recommended radiation therapy (RT) and/or esophagectomy; we found 1403 (3.7%) refused local therapies. Specifically, 890 of 18,942 (4.6%) patients refused surgery and 667 of 31,937 (2.1%) refused RT. Older patients, females, those with unknown lymphovascular space invasion, and those uninsured or on Medicare were more likely to refuse. Those with squamous cell carcinoma, N1 disease, higher incomes, living farther from care, and those who received chemotherapy were less likely to refuse. Five-year OS was decreased in patients who refused (18.1% vs. 27.6%). The survival decrement was present in adenocarcinoma but not squamous cell carcinoma. In patients who received surgery or ≥ 50.4 Gy RT, there was no OS decrement to refusing the other therapy.

Conclusions: We identified characteristics that correlate with refusal of local therapy. Refusal of therapy was associated with decreased OS. Patients who received either surgery or ≥ 50.4 Gy RT had no survival decrement from refusing the opposite modality.
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http://dx.doi.org/10.1245/s10434-020-08761-7DOI Listing
February 2021

Hodgkin Lymphoma, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology.

J Natl Compr Canc Netw 2020 06;18(6):755-781

30National Comprehensive Cancer Network.

The NCCN Clinical Practice Guidelines in Oncology for Hodgkin Lymphoma (HL) provide recommendations for the management of adult patients with HL. The NCCN panel meets at least annually to review comments from reviewers within their institutions, examine relevant data, and reevaluate and update their recommendations. Current management of classic HL involves initial treatment with chemotherapy alone or combined modality therapy followed by restaging with PET/CT to assess treatment response. Overall, the introduction of less toxic and more effective regimens has significantly advanced HL cure rates. This portion of the NCCN Guidelines focuses on the management of classic HL.
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http://dx.doi.org/10.6004/jnccn.2020.0026DOI Listing
June 2020

Preliminary clinical experience with Calypso anchored beacons for tumor tracking in lung SBRT.

Med Phys 2020 Sep 25;47(9):4407-4415. Epub 2020 Jun 25.

Department of Radiation Oncology, University of Utah, Salt Lake City, UT, 84112, USA.

Purpose: To present our preliminary experience with the recently released Calypso lung beacons to track lung tumor location during stereotactic body radiation therapy (SBRT).

Materials/methods: Five recent lung SBRT patients had Calypso lung beacons implanted for tumor tracking during treatment. Beacons were placed by a pulmonologist using fluoroscopic navigation within 1 week prior to planning four-dimensional computed tomography (4DCT) acquisition. Patients were immobilized in a full-body double-vacuum bag. For the first three patients, a verification 4DCT was obtained prior to the first fraction with the patient in the treatment position to assess both beacon migration and motion of tumor and beacons relative to planning day. For each treatment fraction, Calypso was used to position the patient. A verification cone-beam CT (CBCT) confirmed the Calypso-defined target position was appropriate. Real-time Calypso tracking information was also acquired and compared to an action level that was used to determine if the tumor migrated outside of the planning target volume.

Results: For four patients, the implant procedure was well tolerated, with average CBCT-based shifts being within 0.2 mm of the shifts reported by Calypso at the time of imaging. The other patient had a small pneumothorax due to very peripheral tumor location and experienced beacon migration. However, the patient quickly recovered from the pneumothorax, and after deactivating that beacon, motion tracking was possible throughout his treatment.

Conclusions: All patients were successfully treated with SBRT using the newly released Calypso lung beacons, with initial positioning confirmed by this clinic's current clinical standard of CBCT. The system allowed us to validate, with real-time confirmation, that the planned internal target volumes were appropriate to each day's extent of actual tumor motion. An efficient and effective workflow for utilizing the new lung beacons for SBRT treatments was developed.
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http://dx.doi.org/10.1002/mp.14300DOI Listing
September 2020

Analysis of Nonsurgical Treatment Options for Metastatic Rectal Cancer.

Clin Colorectal Cancer 2020 06 12;19(2):91-99.e1. Epub 2020 Mar 12.

Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT. Electronic address:

Introduction: Using a large national registry, we investigated patterns of care and overall survival (OS) for metastatic rectal cancer patients treated with chemotherapy or radiotherapy (RT), or with a multimodal approach.

Patients And Methods: Adult patients with metastatic rectal cancer who did not undergo resection diagnosed from 2004 to 2014 were included. Kaplan-Meier, log-rank, and Cox regression analyses were performed.

Results: We identified 2385 patients. Of these, 1020 patients (43%) received chemotherapy alone, 228 (10%) received RT alone, 850 (36%) received chemotherapy and RT, and 287 (12%) received no treatment. Receipt of chemotherapy alone increased over the study period, and receipt of chemoradiotherapy decreased (P < .01). The only factor predictive of receiving any RT on multivariate analysis was clinical stage T3 disease. Factors predictive of OS on multivariate analysis included receipt of chemotherapy, Hispanic race, income greater than $46,000, and presence of lung metastasis. The OS for patients treated with chemotherapy and RT was not significantly different than chemotherapy alone. Five-year OS with chemotherapy alone, RT alone, chemoradiotherapy, and no treatment were, respectively, 84%, 56%, 79%, and 46%.

Conclusion: Metastatic rectal cancer patients with T3 tumors were more likely to receive RT. Local RT does not improve survival for patients with metastatic rectal cancer who do not also undergo surgery. The use of chemotherapy alone for metastatic rectal cancer is increasing, and chemotherapy is associated with higher OS compared to no treatment and RT alone. This remained true even in patients older than 80 years.
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http://dx.doi.org/10.1016/j.clcc.2019.11.002DOI Listing
June 2020

The impact of squamous cell carcinoma histology on outcomes in nonmetastatic pancreatic cancer.

Cancer Med 2020 03 16;9(5):1703-1711. Epub 2020 Jan 16.

Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, UT, USA.

Background: The prognosis for nonmetastatic, primary pancreatic squamous cell carcinoma (SCC) is thought to be poor compared with adenocarcinoma (AC); however, this is based on limited data. Additionally, the optimal definitive treatment strategy for nonmetastatic pancreatic SCC is unknown.

Methods: We analyzed patients with nonmetastatic pancreatic cancer using the National Cancer Database for patients diagnosed from 2006 to 2014. Patients were analyzed according to histology-only AC, adenosquamous carcinoma (A-SCC), and SCC were included. The primary endpoint was overall survival (OS) from the time of diagnosis.

Results: A total of 94 928 cases were included; 94 016 AC, 757 A-SCC, and 155 SCC. Median OS was lower for SCC (8.67 months), compared to AC (13.93 months) and A-SCC (12.71 months, P < .001). SCC was resected less often (25.5% vs 46.7% and 74.5%). On subgroup analysis of patients with pancreatic SCC, factors on multivariate analysis associated with improved survival included surgery (HR 0.19, P < .001), and chemotherapy (HR 0.22, P = .01). In 38 patients with SCC undergoing surgical resection, median OS improved (MS = 6.8 months without surgery vs 21.3 months with surgery, P < .001).

Conclusions: Nonmetastatic pancreatic SCC presents with more advanced disease, which is less often surgically resected or treated with any definitive local therapy. In contrast, AC and A-SCC behave more similarly and have higher surgical resection rates and improved survival. In patients with nonmetastatic SCC of the pancreas, surgical resection provides the most significant survival benefit, with systemic chemotherapy providing a less significant benefit, and localized radiation providing no statistical benefit for any subgroup.
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http://dx.doi.org/10.1002/cam4.2851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050091PMC
March 2020

Stereotactic body radiotherapy versus percutaneous local tumor ablation for early-stage non-small cell lung cancer.

Lung Cancer 2019 12 16;138:6-12. Epub 2019 Sep 16.

Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA. Electronic address:

Objectives: To compare patterns of care and overall survival (OS) between stereotactic body radiotherapy (SBRT) and percutaneous local tumor ablation (LTA) for non-surgically managed early-stage non-small-cell lung cancer (NSCLC).

Materials And Methods: The National Cancer Database (NCDB) was queried from 2004 to 2014 for adults with non-metastatic, node-negative invasive adenocarcinoma or squamous cell carcinoma of the lung with primary tumor size ≤5.0 cm who did not undergo surgery or chemotherapy and received SBRT or LTA. Patterns of care were assessed with multivariate logistic regression. After propensity-score weighting with generalized boosted regression, OS was assessed with univariate and doubly-robust multivariate Cox regression.

Results: Of 15,792 patients, 14,651 (93%) received SBRT and 1141 (7%) received LTA. Increasing age (OR 1.01, p = .035), treatment at an academic institution (OR 2.94, p < .001), increasing tumor size (OR 1.05, p < .001), and more recent year of diagnosis (OR 1.43, p < .001) were predictive of treatment with SBRT, whereas comorbidities (OR 0.74, p = .003) and treatment at a high-volume facility (OR 0.05, p < .001) were predictive for LTA. At a median follow-up of 26.2 months, SBRT was associated with improved OS relative to LTA within a propensity-score weighted doubly-robust multivariate analysis (HR 0.71, p < .001). On weighted subgroup analyses, improved OS was observed with SBRT for tumor sizes >2.0 cm (HR 0.72, p < .001) and for those treated at high-volume facilities (HR 0.71, p < .001). No OS difference was found with SBRT or LTA in tumor sizes ≤2.0 cm (HR 0.90, p = .227).

Conclusion: Within the NCDB, SBRT was more commonly utilized and was associated with improved OS when compared to percutaneous LTA for patients with non-surgically managed early-stage NSCLC. Patients with small tumor volumes likely represent an appropriate population for future prospective randomized comparisons between SBRT and LTA.
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http://dx.doi.org/10.1016/j.lungcan.2019.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082035PMC
December 2019

Haploidentical hematopoietic cell transplantation for mycosis fungoides/Sezary syndrome.

Leuk Lymphoma 2020 01 27;61(1):231-233. Epub 2019 Aug 27.

Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.

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http://dx.doi.org/10.1080/10428194.2019.1658106DOI Listing
January 2020

Mental Health Disorders are More Common in Colorectal Cancer Survivors and Associated With Decreased Overall Survival.

Am J Clin Oncol 2019 04;42(4):355-362

Department of Family and Preventive Medicine, Division of Public Health, Huntsman Cancer Institute, University of Utah School of Medicine.

Objectives: To determine the risk and risk factors for mental illness among colorectal cancer (CRC) survivors across short-term and long-term follow-up periods.

Methods: We used the Utah Cancer Registry to identify CRC survivors diagnosed between 1997 and 2013. Mental health diagnoses were available in electronic medical records and statewide facilities data that were linked by the Utah Population Database. CRC survivors were matched to individuals from a general population cohort. The risk of developing a mental illness was compared between cohorts. The association between mental illness and mortality was also analyzed.

Results: In total, 8961 CRC survivors and 35,897 individuals in a general population cohort were identified. CRC survivors were at increased risk for any mental health diagnosis at 0 to 2 years (hazard ratio [HR], 3.70; 95% confidence interval [CI], 3.47-3.95), >2 to 5 years (HR, 1.23; 95% CI, 1.09-1.38), and >5 years (HR, 1.20; 95% CI, 1.07-1.36) after cancer diagnosis. CRC survivors were also at increased risk of depressive disorders specifically during the same time periods. At >5 years, CRC survivors still had an increased risk of developing many mental health diagnoses. Factors associated with increased risk of any mental health disorder among CRC survivors included colostomy and Charlson Comorbidity Index of 1+. There was an increased risk of death for CRC survivors diagnosed with any mental health disorder (HR, 2.18; 95% CI, 2.02-2.35) and depression (HR, 2.10; 95% CI, 1.92-2.28).

Conclusions: CRC survivors are at increased risk for mental health disorders in the short-term and long-term. Survivors who develop mental health disorders also experience decreased survival.
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http://dx.doi.org/10.1097/COC.0000000000000529DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6433523PMC
April 2019

Hypoxia imaging in upper gastrointestinal tumors and application to radiation therapy.

J Gastrointest Oncol 2018 Dec;9(6):1044-1053

Center for Quantitative Cancer Imaging, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.

Survival for upper gastrointestinal tumors remains poor, likely in part due to treatment resistance associated with intratumoral hypoxia. In this review, we highlight advances in nuclear medicine imaging that allow for characterization of in vivo tumor hypoxia in esophageal, pancreatic, and liver cancers. Strategies for adaptive radiotherapy in upper gastrointestinal tumors are proposed that would apply information gained through hypoxia imaging to the creation of personalized radiotherapy treatment plans able to overcome hypoxia-induced treatment resistance, minimize treatment-related toxicities, and improve patient outcomes.
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http://dx.doi.org/10.21037/jgo.2018.09.15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286953PMC
December 2018

Large database utilization in health outcomes research in pancreatic cancer: an update.

J Gastrointest Oncol 2018 Dec;9(6):996-1004

Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA.

We sought to review published aggregate dataset studies on pancreatic cancer in the national and international settings, discuss the advantages and disadvantages these datasets possess, and possible future directions. A combination of Google Scholar, PubMed, and MEDLINE were used with search terms "pancreatic cancer" + "resectable" + "national cancer database", "pancreatic cancer" + "unresectable" + "national cancer database" and more broadly "borderline resectable pancreatic cancer", "locally advanced pancreatic cancer", "unresectable pancreatic cancer", and "resectable pancreatic cancer". Original articles and abstracts from this search were included, including data from the Surveillance, Epidemiology, and End Results (SEER) database, National Cancer Database (NCDB), and SEER-Medicare within the United States (US), as well as international database studies. Multiple database studies have been published regarding the role for radiotherapy in resected pancreatic cancer (n=6), the timing of additional therapy in resectable pancreatic cancer (n=4), and the role for radiotherapy and resection in locally advanced pancreatic cancer (LAPC) (n=4). Studies from both SEER and NCDB found a survival benefit to post-operative radiotherapy. In resectable pancreatic cancer, neoadjuvant treatment was found to be superior to adjuvant (NCDB). Chemoradiotherapy was found to be more beneficial than chemotherapy alone in LAPC, and patients who received highly-conformal or stereotactic body radiotherapy (SBRT) had improved survival compared to either conformal radiotherapy or chemotherapy alone. These studies also found that up to 10% of patients underwent resection, with a 90% margin-negative rate, and either one-half to one-third the risk of death of non-surgical patients. Criticism of large datasets includes lack of granularity of performance status, diagnosis, treatment, and outcomes-related data compared to properly administered prospective trials, as well as cross-over between treatment arms that cannot be accounted for, and concerns over quality of data represented. The US has witnessed a growing number of comparative effectiveness studies in pancreatic cancer. When taken together, certain themes emerge that are consistent with both single-institution data and clinical trials. These studies have also provided insight into questions not readily answerable by clinical trials. However, they require caution in interpretation.
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http://dx.doi.org/10.21037/jgo.2018.05.15DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286942PMC
December 2018

Daily breathing inconsistency in pancreas SBRT: a 4DCT study.

J Gastrointest Oncol 2018 Dec;9(6):989-995

Department of Radiation Oncology, University of Utah Huntsman Cancer Hospital, Salt Lake City, UT, USA.

Background: Stereotactic body radiation therapy (SBRT) treatments of pancreatic cancer typically employ relatively small margins. This study characterizes the motion of high visibility structures in close proximity to the pancreas to determine how much the motion envelope of such a structure changes due to respiratory variation between fractions.

Methods: Fanbeam, four-dimensional computed tomography (4DCT) studies acquired initially for planning and again prior to each treatment for 6 patients were used to fully characterize the change in motion of high-contrast structures in close proximity to the pancreas.

Results: Three of the six patients investigated had structures that showed a change in motion over the course of treatment that would not have been covered when using the typical 3 mm planning target volume (PTV) margins. For most of these large changes in motion envelope, a 4 mm uniform PTV margin would have allowed for coverage of the tumor.

Conclusions: Half of the patients showed a change in motion envelope greater than would be covered by the commonly used PTV margins in pancreas SBRT. This shows that the impact of small margins must be very carefully considered during the planning process.
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http://dx.doi.org/10.21037/jgo.2018.09.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6286933PMC
December 2018

Treatment of primary rectal adenocarcinoma after prior pelvic radiation: The role of hyperfractionated accelerated reirradiation.

Adv Radiat Oncol 2018 Oct-Dec;3(4):595-600. Epub 2018 Jul 17.

Department of Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas.

Purpose: Previous studies have reported that hyperfractionated accelerated reirradiation can be used as part of multimodality treatment of locally recurrent rectal cancer with acceptable toxicity and promising outcomes. The purpose of this study was to evaluate the outcomes and toxicity of hyperfractionated accelerated reirradiation for patients with primary rectal adenocarcinoma and a history of prior pelvic radiation for other primary malignancies.

Methods And Materials: We identified 10 patients with a prior history of pelvic radiation for other primary malignancies who were treated with hyperfractionated accelerated reirradiation for primary rectal adenocarcinoma. Radiation therapy was administered with 1.5 Gy twice daily fractions to a total dose of 39 Gy to 45Gy.

Results: The median follow-up time was 3.2 years (range, 0.6-9.0 years). Seven of 10 patients received surgery after reirradiation. The 3-year freedom-from-local-progression rate was 62% for all patients and 80% for patients who underwent surgery. The 3-year overall survival rate was 100%, with 3 deaths occurring at 4.7, 6.5, and 9.0 years after reirradiation. One patient had an acute Grade 3 toxicity of diarrhea, and 1 patient experienced a late Grade 3 toxicity of sacral insufficiency fracture.

Conclusions: Hyperfractionated accelerated reirradiation was well tolerated with promising rates of freedom from local progression and overall survival in patients with primary rectal cancer with a history of prior pelvic radiation therapy. This approach, along with concurrent chemotherapy and surgery, appears to be a viable treatment strategy for this patient population.
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http://dx.doi.org/10.1016/j.adro.2018.07.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200883PMC
July 2018

Benefit of adjuvant chemotherapy based on lymph node involvement for oesophageal cancer following trimodality therapy.

ESMO Open 2018 25;3(5):e000386. Epub 2018 Jul 25.

Department of Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA. Electronic address:

Background: Oesophageal cancer (OC) survival rates have improved since the widespread adoption of neoadjuvant chemoradiation therapy (NACRT) followed by oesophagectomy (trimodality therapy). Unfortunately, the overall prognosis for patients with locally advanced disease remains poor. In this study, we sought to assess the effect of adjuvant chemotherapy (AC) in patients treated with trimodality therapy.

Methods: Using the National Cancer Database we retrospectively identified 6785 patients with locally advanced (cT1b-T4a, N0-N+, M0) OC who were treated with trimodality therapy from 2006 to 2014. Patients were separated based on receipt of AC (n=463), as well as clinical and pathological lymph node involvement. Overall survival (OS) between groups was compared using the Kaplan-Meier method and Cox proportional hazard modelling.

Results: Based on multivariate analysis, AC was associated with a statistically significantly reduced risk of death (HR 0.77, p<0.001). Subgroup analysis revealed that AC was associated with reduced risk of death compared with NACRT alone in the cN+/pN0 (median OS 64 vs 43 months; p=0.019) and the cN+/pN+ (median OS 27 vs 22 months; p=0.010) groups, but not in the cN0/pN0 (median OS 48 vs 49 months; p=0.253) or cN0/pN+ (median OS 31 vs 24 months; p=0.077) groups.

Conclusion: AC following trimodality therapy may improve survival in patients with locally advanced OC. Patients who undergo lymph node downstaging may be the most likely to benefit from AC. Prospective studies are needed to confirm this finding.
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http://dx.doi.org/10.1136/esmoopen-2018-000386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069924PMC
July 2018

Adjuvant therapy for resected pN2 non-small cell lung cancer: sequence is not all that matters.

J Thorac Dis 2018 Jun;10(Suppl 17):S2097-S2099

Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.

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http://dx.doi.org/10.21037/jtd.2018.05.152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036049PMC
June 2018

Definitive radiation therapy for hepatocellular carcinoma with portal vein tumor thrombus.

Clin Transl Radiat Oncol 2017 Jun 7;4:39-45. Epub 2017 Jun 7.

The University of Texas MD Anderson Cancer Center Division of Radiation Oncology, Houston, TX, United States.

Background: The purpose of this study is to review the results of radiation therapy (RT) for hepatocellular carcinoma (HCC) with portal venous tumor thrombus (PVTT) in a Western patient population.

Methods: Thirty-four patients with HCC PVTT treated from 2007 to 2014 with RT were identified. Biologically effective dose (BED) was calculated for each patient, and greater than the median dose delivered (75 Gray (Gy)) was evaluated as a potential prognostic factor. Survival was compared and independent prognostic variables were evaluated by a Cox proportional hazards regression model.

Results: Twenty-six patients (76.5%) exhibited a radiographic response to RT, and 10 patients (29.4%) ultimately developed local failure. Local control, liver control, distant control and OS at one year were 57.1%, 36.4%, 55.2% and 57.4%, respectively. Patients who received a BED >75 Gy had a significantly better local control at 1 year (93.3% vs 45.6%; Log Rank p = 0.0184). Patients who received a BED >75 Gy also had significantly better median survival (24.7mo vs 6.1mo) and 1-year overall survival (76.5% vs 30.0%) when compared with BED ≤75 Gy (Log-Rank p = 0.002).

Conclusion: Our data suggest that RT should be considered for well-selected patients with HCC and PVTT for the purpose of improving local control and potentially prolonging the time to worsening venous obstruction and liver failure. When feasible, dose-escalation should be considered with a target BED of >75 Gy if normal organ dose constraints can be safely met.
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http://dx.doi.org/10.1016/j.ctro.2017.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833919PMC
June 2017

NCCN Guidelines Insights: Hodgkin Lymphoma, Version 1.2018.

J Natl Compr Canc Netw 2018 Mar;16(3):245-254

The NCCN Clinical Practice Guidelines in Oncology for Hodgkin Lymphoma (HL) provide recommendations for the management of adult patients with HL. The NCCN Guidelines Panel meets at least annually to review comments from reviewers within the NCCN Member Institutions, examine relevant data, and reevaluate and update the recommendations. These NCCN Guidelines Insights summarize recent updates centered on treatment considerations for relapsed/refractory classic HL.
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http://dx.doi.org/10.6004/jnccn.2018.0013DOI Listing
March 2018

Outcomes of stereotactic radiosurgery of brain metastases from neuroendocrine tumors.

Neurooncol Pract 2018 Mar 25;5(1):37-45. Epub 2017 May 25.

Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: Stereotactic radiosurgery (SRS) is an established treatment for brain metastases, yet little is known about SRS for neuroendocrine tumors given their unique natural history.

Objective: To determine outcomes and toxicity from SRS in patients with brain metastases arising from neuroendocrine tumors.

Methods: Thirty-three patients with brain metastases from neuroendocrine tumors who underwent SRS were retrospectively reviewed. Median age was 61 years and median Karnofsky performance status was 80. Primary sites were lung (87.9%), cervix (6.1%), esophagus (3%), and prostate (3%). Ten patients (30.3%) received upfront SRS, 7 of whom had neuroendocrine tumors other than small cell lung carcinoma. Kaplan-Meier survival and Cox regression analyses were performed to determine prognostic factors for survival.

Results: With median follow-up after SRS of 5.3 months, local and distant brain recurrence developed in 5 patients (16.7%) and 20 patients (66.7%), respectively. Median overall survival (OS) after SRS was 6.9 months. Patients with progressive disease per Response Assessment in Neuro-Oncology-Brain Metastases (RANO-BM) criteria at 4 to 6 weeks after SRS had shorter median time to developing recurrence at a distant site in the brain and shorter OS than patients without progressive disease: 1.4 months and 3.3 months vs 11.4 months and 12 months, respectively (both < .001). Toxicity was more likely in lesions of small cell histology than in lesions of other neuroendocrine tumor histology, 15.7% vs 3.3% ( = .021). No cases of grade 3 to 5 necrosis occurred.

Conclusions: SRS is an effective treatment option for patients with brain metastases from neuroendocrine tumors with excellent local control despite slightly higher toxicity rates than expected. Progressive disease at 4 to 6 weeks after SRS portends a poor prognosis.
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http://dx.doi.org/10.1093/nop/npx009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6655365PMC
March 2018

Value of surgical resection and timing of therapy in patients with pancreatic cancer at high risk for positive margins.

ESMO Open 2018 27;3(1):e000282. Epub 2018 Jan 27.

Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA.

Background: Surgical resection remains the best chance at long-term survival in pancreatic cancer, though margin-positive resections are associated with diminished survival. We examined the effect of margin-positive resection on survival, as well as the role and timing of additional therapies through the National Cancer Database (NCDB).

Patients And Methods: Patients with stage IIA-III pancreatic adenocarcinoma diagnosed from 2004 to 2013 were identified in NCDB. Survival was compared using univariate and multivariate Cox proportional hazards modelling for patients who underwent surgery with negative (R0), microscopically positive (R1) and macroscopically positive (R2) margins or non-surgical treatment. We further analysed patients by margin status, timing of additional therapy (neoadjuvant therapy (NAT) vs adjuvant therapy (AT) vs none) and clinical stage.

Results: We analysed 44 852 patients. Median survival (MS) for patients who did not undergo surgery was 10.3 months, compared with 19.7 months for R0 (P<0.001), 14.3 months for R1 (P<0.001) and 9.8 months (P=0.07) for R2 resections. NAT (MS 23.2 months) was associated with improved survival compared with AT (MS 21.5 months) in negative-margin patients and equivalent (MS 17.6 months) to AT (MS 16.8 months) in positive-margin patients. Survival for stage III NAT positive-margin patients (MS 19.8 months) was equivalent to AT after negative margins (MS 18.4 months, P=1.00). Improved R0 rates were seen with NAT (88% vs 81%, P<0.001), especially in stage III patients (85% vs 59%, P<0.001).

Conclusion: R1 resections portend poorer survival than R0 but do not negate the benefit of surgery when additional therapy is given. NAT was associated with improved R0 rates and improved survival for stage III positive-margin patients.
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http://dx.doi.org/10.1136/esmoopen-2017-000282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786921PMC
January 2018

Sequencing of Postoperative Radiotherapy and Chemotherapy for Locally Advanced or Incompletely Resected Non-Small-Cell Lung Cancer.

J Clin Oncol 2018 02 13;36(4):333-341. Epub 2017 Dec 13.

Samual Francis, Andrew Orton, Randa Tao, Ying J. Hitchcock, Wallace Akerley, and Kristine E. Kokeny, University of Utah Huntsman Cancer Institute; Greg Stoddard, University of Utah, Salt Lake City, UT.

Purpose Although several feasibility studies have demonstrated the safety of adjuvant concurrent chemoradiotherapy (CRT) for locally advanced or incompletely resected non-small-cell lung cancer (NSCLC), it remains uncertain whether this approach is superior to sequential chemotherapy followed by postoperative radiotherapy (C→PORT). We sought to determine the most effective treatment sequence. Patients and Methods Using the National Cancer Database, we selected two cohorts of patients with nonmetastatic NSCLC who had received at least a lobectomy followed by multiagent chemotherapy and radiotherapy; cohort one included patients with R0 resection and pN2 disease, whereas cohort two included patients with R1-2 resection regardless of nodal status. Overall survival (OS) was examined using a propensity score-matched analysis with a shared frailty Cox regression. Results A total of 747 patients in cohort one and 277 patients in cohort two were included, with a median follow-up of 32.8 and 27.9 months, respectively. The median OS was 58.8 months for patients who received C→PORT versus 40.4 months for patients who received CRT in cohort one (log-rank P < .001). For cohort two, the median OS was 42.6 months for patients who received C→PORT versus 38.5 months for patients who received CRT (log-rank P = .42). After propensity score matching, C→PORT remained associated with improved OS compared with CRT in cohort one (hazard ratio, 1.35; P = .019), and there was no statistical difference in OS between the sequencing groups for cohort two (hazard ratio, 1.35; P = .19). Conclusion Patients with NSCLC who undergo R0 resection and are found to have pN2 disease have improved outcomes when adjuvant chemotherapy is administered before, rather than concurrently with, radiotherapy. For patients with positive margins after surgery, there is not a clear association between treatment sequencing and survival.
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http://dx.doi.org/10.1200/JCO.2017.74.4771DOI Listing
February 2018

Chemoradiation Therapy for Unresected Extrahepatic Cholangiocarcinoma: A Propensity Score-Matched Analysis.

Ann Surg Oncol 2017 Dec 17;24(13):4001-4008. Epub 2017 Oct 17.

Department of Radiation Oncology, University of Utah, Salt Lake City, UT, USA.

Background: Unresected extrahepatic cholangiocarcinoma (uEHCC) remains a deadly disease. Guidelines for uEHCC recommend either chemotherapy alone (CT) or chemoradiotherapy (CRT). This study used the National Cancer Database (NCDB) to compare outcomes for patients treated with CT and those who underwent CRT.

Methods: Patients with initially diagnosed non-metastatic uEHCC from 2004 to 2014 were identified. Using Chi square analysis, patients who underwent CT were compared with those who received CRT. Uni- and multivariate Cox regression analyses were used to compare characteristics related to survival. Propensity score matching and shared frailty analysis were undertaken to correct for baseline differences between the two groups. Additional analyses were performed to compare survival for the minority of patients who underwent surgery and advanced-stage patients.

Results: The study identified 2996 patients with uEHCC. Chemoradiation was associated with better survival (median survival [MS], 14.5 months; hazard ratio [HR] 0.84; p < 0.001) than CT alone (MS, 12.6 months). Induction of CT before CRT was associated with a trend toward decreased risk of death compared with concurrent CRT (HR 0.81; p = 0.051). For the patients able to undergo surgery after initial treatment, MS was 24.5 months (HR 0.38; p < 0.001) versus 12.2 months for those who had no surgery. For these patients, CRT also was associated with better survival (MS, 31.2 months; HR 0.66; p = 0.001) than CT (MS, 22.1 months). Positive margins at surgery yielded survival equivalent to that with no surgery.

Conclusion: Although CRT may be associated with slightly better survival in uEHCC than CT alone, the majority of the benefit was observed for patients able to undergo eventual surgery.
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http://dx.doi.org/10.1245/s10434-017-6131-9DOI Listing
December 2017

Spine stereotactic radiosurgery for metastatic sarcoma: patterns of failure and radiation treatment volume considerations.

J Neurosurg Spine 2017 Sep 23;27(3):303-311. Epub 2017 Jun 23.

Departments of 1 Radiation Oncology.

OBJECTIVE Given the relatively lower radiosensitivity of sarcomas and the locally infiltrative patterns of spread, the authors sought to investigate spine stereotactic radiosurgery (SSRS) outcomes for metastatic sarcomas and to analyze patterns of failure. METHODS The records of 48 patients with 66 sarcoma spinal metastases consecutively treated with SSRS between 2002 and 2013 were reviewed. The Kaplan-Meier method was used to estimate rates of overall survival (OS) and local control (LC). Local recurrences were categorized as occurring infield (within the 95% isodose line [IDL]), marginally (between the 20% and 95% IDLs), or out of field. RESULTS Median follow-up time was 19 months (range 1-121 months), and median age was 53 years (range 17-85 years). The most commonly treated histology was leiomyosarcoma (42%). Approximately two-thirds of the patients were treated with definitive SSRS (44 [67%]) versus postoperatively (22 [33%]). The actuarial 1-year OS and LC rates were 67% and 81%, respectively. Eighteen patients had a local relapse, which was more significantly associated with postoperative SSRS (p = 0.04). On multivariate modeling, receipt of postoperative SSRS neared significance for poorer LC (p = 0.06, subhazard ratio [SHR] 2.33), while only 2 covariates emerged as significantly correlated with LC: 1) biological equivalent dose (BED) > 48 Gy (vs BED ≤ 48 Gy, p = 0.006, SHR 0.21) and 2) single vertebral body involvement (vs multiple bodies, p = 0.03, SHR 0.27). Of the 18 local recurrences, 14 (78%) occurred at the margin, and while the majority of these cases relapsed within the epidural space, 4 relapsed within the paraspinal soft tissue. In addition, 1 relapse occurred out of field. Finally, the most common acute toxicity was fatigue (15 cases), with few late toxicities (4 insufficiency fractures, 3 neuropathies). CONCLUSIONS For metastatic sarcomas, SSRS provides durable tumor control with minimal toxicity. High-dose single-fraction regimens offer optimal LC, and given the infiltrative nature of sarcomas, when paraspinal soft tissues are involved, larger treatment volumes may be warranted.
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http://dx.doi.org/10.3171/2017.1.SPINE161045DOI Listing
September 2017

Multiagent induction chemotherapy followed by chemoradiation is associated with improved survival in locally advanced pancreatic cancer.

Cancer 2017 Oct 16;123(19):3816-3824. Epub 2017 Jun 16.

Department of Radiation Oncology, Intermountain Medical Center, Murray, Utah.

Background: The role of chemoradiotherapy (CRT) in locally advanced pancreatic cancer (LAPC) is uncertain after multiple randomized clinical trials have yielded mixed results. The authors used the National Cancer Data Base (NCDB) to determine whether CRT yields a survival benefit compared with chemotherapy alone (CT).

Methods: Patients with nonmetastatic LAPC diagnosed during 2004 through 2014 were identified in the NCDB. Patients who received CT were compared with those who received CRT using chi-square analysis. Univariate and multivariate Cox regression analyses were used to compare demographic, clinical, and treatment characteristics that were predictive of survival. Propensity score matching and shared frailty analysis were done. Subgroup analyses were undertaken to examine patients who underwent pancreatectomy and cohorts of patients who received different CT or CRT regimens.

Results: In total, 8689 patients with LAPC were identified. CRT was associated with improved survival (median survival [MS], 13.5 months) compared with CT (MS, 10.6 months) on multivariate analysis (hazard ratio [HR], 0.80; P < .001). Induction chemotherapy before CRT (HR, 0.67; P < .001) and multiagent chemotherapy (HR, 0.72; P < .001) were also identified as independent predictors of survival compared with concurrent CRT and single-agent CT, respectively. Patients in the CRT group who received multiagent induction chemotherapy had superior MS and pancreatectomy rates (MS, 17.5 months; HR, 0.70; P < .001; pancreatectomy rate, 10%) compared with those who received multiagent CT alone (MS, 12.4 months; pancreatectomy rate, 3.3%). Patients who underwent pancreatectomy experienced improved survival (MS, 22 vs 10.6 months; HR, 0.39; P < .001).

Conclusions: In this NCDB analysis, maximizing systemic chemotherapy before CRT improved survival compared with CT alone in patients with LAPC. Continued analysis of CRT in properly selected patients after maximized systemic therapy is needed. Cancer 2017;123:3816-24. © 2017 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30780DOI Listing
October 2017

Prospective Qualitative and Quantitative Analysis of Real-Time Peer Review Quality Assurance Rounds Incorporating Direct Physical Examination for Head and Neck Cancer Radiation Therapy.

Int J Radiat Oncol Biol Phys 2017 07 19;98(3):532-540. Epub 2016 Nov 19.

Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address:

Purpose: Our department has a long-established comprehensive quality assurance (QA) planning clinic for patients undergoing radiation therapy (RT) for head and neck cancer. Our aim is to assess the impact of a real-time peer review QA process on the quantitative and qualitative radiation therapy plan changes in the era of intensity modulated RT (IMRT).

Methods And Materials: Prospective data for 85 patients undergoing head and neck IMRT who presented at a biweekly QA clinic after simulation and contouring were collected. A standard data collection form was used to document alterations made during this process. The original pre-QA clinical target volumes (CTVs) approved by the treating-attending physicians were saved before QA and compared with post-QA consensus CTVs. Qualitative assessment was done according to predefined criteria. Dice similarity coefficients (DSC) and other volume overlap metrics were calculated for each CTV level and were used for quantitative comparison. Changes are categorized as major, minor, and trivial according to the degree of overlap. Patterns of failure were analyzed and correlated to plan changes.

Results: All 85 patients were examined by at least 1 head and neck subspecialist radiation oncologist who was not the treating-attending physician; 80 (94%) were examined by ≥3 faculty members. New clinical findings on physical examination were found in 12 patients (14%) leading to major plan changes. Quantitative DSC analysis revealed significantly better agreement in CTV1 (0.94 ± 0.10) contours than in CTV2 (0.82 ± 0.25) and CTV3 (0.86 ± 0.2) contours (P=.0002 and P=.03, respectively; matched-pair Wilcoxon test). The experience of the treating-attending radiation oncologist significantly affected DSC values when all CTV levels were considered (P=.012; matched-pair Wilcoxon text). After a median follow-up time of 38 months, only 10 patients (12%) had local recurrence, regional recurrence, or both, mostly in central high-dose areas.

Conclusions: Comprehensive peer review planning clinic is an essential component of IMRT QA that led to major changes in one-third of the study population. This process ensured safety related to target definition and led to favorable disease control profiles, with no identifiable recurrences attributable to geometric misses or delineation errors.
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http://dx.doi.org/10.1016/j.ijrobp.2016.11.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5438284PMC
July 2017

Hyperfractionated accelerated reirradiation for rectal cancer: An analysis of outcomes and toxicity.

Radiother Oncol 2017 01 3;122(1):146-151. Epub 2017 Jan 3.

Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, USA.

Background And Purpose: To evaluate outcomes and toxicity in patients treated with hyperfractionated pelvic reirradiation for recurrent rectal cancer.

Materials And Methods: 102 patients with recurrent rectal adenocarcinoma were treated with pelvic reirradiation with a hyperfractionated accelerated approach, consisting of 1.5Gy twice daily fractions to a total dose of 30-45Gy (median 39Gy), with the most common total dose 39Gy (n=90, 88%). The median dose of prior pelvic radiation therapy (RT) was 50.4Gy (range: 25-63Gy).

Results: The median follow-up was 40months for living patients (range, 3-150months). The 3-year freedom from local progression (FFLP) rate was 40% and the 3-year overall survival (OS) rate was 39%. Treatment with surgery was significantly associated with improved FFLP and OS, with 3-year FFLP rate of 49% vs. 30% (P=0.013), and 3-year OS rate of 62% vs. 20% (P<0.0001), compared to those without surgery. The actuarial 3-year rate of grade 3-4 late toxicity was 34%; patients who underwent surgery had a significantly higher rate of grade 3-4 late toxicity compared to those without surgery (54% vs. 16%, P=0.001).

Conclusions: This large, retrospective, single-institution study shows that hyperfractionated accelerated reirradiation was well tolerated. The rate of FFLP was promising, given that the study comprised heavily pre-treated patients with recurrences. Rates of FFLP and OS were particularly impressive in patients who underwent both reirradiation and surgery.
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http://dx.doi.org/10.1016/j.radonc.2016.12.015DOI Listing
January 2017

Local therapy reduces the risk of liver failure and improves survival in patients with intrahepatic cholangiocarcinoma: A comprehensive analysis of 362 consecutive patients.

Cancer 2017 04 16;123(8):1354-1362. Epub 2016 Dec 16.

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background: Treatment methods for intrahepatic cholangiocarcinoma (ICC) have improved, but their impact on outcome remains unclear. We evaluated the outcomes of patients definitively treated with resection, radiation, and chemotherapy for ICC, stratified by era.

Methods: Clinico-pathologic characteristics, cause of death, disease-specific survival (DSS), and intrahepatic progression-free survival (IPFS) were compared among patients who underwent resection, radiation, or chemotherapy as definitive treatment strategies for ICC (without distant organ metastasis) between 1997 and 2015. Variables were also analyzed by era (1997-2006 [early] or 2007-2015 [late]) within each group.

Results: Among 362 patients in our cohort, 122 underwent resection (early, 38; late, 84), 85 underwent radiation (early, 17; late, 68), and 148 underwent systemic chemotherapy alone (early, 51; late, 97) as definitive treatment strategies, and 7 patients received best supportive care. In the resection group, the 3-year DSS rate was 58% for the early era and 67% for the late era (P = .036), and the 1-year IPFS was 50% for the early era and 75% for the late era (P = .048). In the radiation group, the 3-year DSS was 12% for the early era and 37% for the late era (P = .048), and the 1-year IPFS was 48% for the early era and 64% for the late era (P = .030). In the chemotherapy group, DSS and IPFS did not differ by era. Patients treated with chemotherapy developed liver failure at the time of death significantly more frequently than patients treated with resection (P < .001) or radiation (P < .001). Multivariable analysis identified local therapy (resection or radiation) as a sole predictor of death without liver failure.

Conclusion: Survival outcomes have improved for local therapy-based definitive treatment strategies for ICC, which may be attributable to maintaining control of intrahepatic disease, thereby reducing the occurrence of death due to liver failure. Cancer 2017;123:1354-1362. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5384875PMC
April 2017

Incidence and predictors of chest wall toxicity after high-dose radiation therapy in 15 fractions.

Pract Radiat Oncol 2017 Jan - Feb;7(1):63-71. Epub 2016 Jun 3.

Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address:

Purpose: Fifteen fraction treatment schedules are increasingly used to deliver high doses of radiation therapy (RT) to both lung and hepatobiliary malignancies. The purpose of our study was to examine the incidence and predictors of chest wall (CW) toxicity in patients treated with this regimen.

Methods And Materials: We evaluated 135 patients treated with RT to doses ≥52.5 Gy in 15 fractions for thoracic and hepatobiliary malignancies between January 2009 and December 2012. We documented patient characteristics and CW dosimetric parameters for each case. Toxicity was scored using the Common Terminology Criteria for Adverse Events, version 4.0, criteria for radiation dermatitis and CW pain. Patient characteristics and CW dosimetric parameters were evaluated for their association with CW toxicity using proportional hazards regression.

Results: Median follow-up was 9 months from the start of RT. Forty-eight patients (36%) developed dermatitis at a median time of 18 days. In multivariable analysis, the absolute volume of CW (in cm) receiving 40 Gy (V40) ≥120 cm was associated with the occurrence of dermatitis (hazard ratio, 3.12; 95% confidence interval, 1.74-5.60; P < .001). Twenty-one patients (16%) developed CW pain (20 grade 1, 1 grade 2) at a median time of 3 months. In multivariable analysis, CW V40 ≥150 cm was associated with the occurrence of CW pain (hazard ratio, 2.65; 95% confidence interval, 1.12-6.24; P = .03). The absolute rate of CW pain in patients with V40 <150 cm was 11% versus 26% in patients with V40 ≥150 cm (P = .03).

Conclusions: Hypofractionated RT with 15 fraction regimens results in an acceptable incidence of CW toxicity, specifically CW pain. We recommend a dose constraint of V40 <150 cm to minimize this adverse event.
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http://dx.doi.org/10.1016/j.prro.2016.05.009DOI Listing
April 2017