Publications by authors named "Richard Li"

95 Publications

Characterizing impact of positive lymph node number in endometrial cancer using machine-learning: A better prognostic indicator than FIGO staging?

Gynecol Oncol 2021 Nov 15. Epub 2021 Nov 15.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA. Electronic address:

Background: Number of involved lymph nodes (LNs) is a crucial stratification factor in staging of numerous disease sites, but has not been incorporated for endometrial cancer. We evaluated whether number of involved LNs provide improved prognostic value.

Patients And Methods: Patients diagnosed with node-positive endometrial adenocarcinoma without distant metastasis were identified in the National Cancer Database. We trained a machine-learning based model of overall survival. Shapley additive explanation values (SHAP) based on the model were used to identify cutoffs of number of LNs involved. Results were validated using a Cox proportional hazards regression model.

Results: We identified 11,381 patients with endometrial cancer meeting the inclusion criteria. Using the SHAP values, we selected the following thresholds: 1-3 LNs, 4-5 LNs, and 6+ LNs. The 3-year OS was 82.0% for 1-3 LNs, 74.3% for 4-5 LNs (hazard ratio [HR] 1.38; p < 0.001), and 59.9% for 6+ LNs (HR 2.23; p < 0.001). On univariate Cox regression, PA nodal involvement was a significant predictor of OS (HR 1.20; p < 0.001) but was not significant on multivariate analysis when number of LNs was included (HR 1.05; p = 0.273). Additionally, we identified an interaction between adjuvant therapy and number of involved LNs. Patients with 1-3 involved LNs had 3-year OS of 85.2%, 78.7% and 74.2% with chemoradiation (CRT), chemotherapy, and radiation, respectively. Patients with 6+ involved LNs had 3-yr OS of 67.8%, 49.6%, and 48.9% with CRT, chemotherapy, and radiation, respectively (p < 0.001).

Conclusion: Number of involved LNs is a stronger prognostic and predictive factor compared to PA node involvement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ygyno.2021.11.007DOI Listing
November 2021

A cloud-based toolbox for the versatile environmental annotation of biodiversity data.

PLoS Biol 2021 Nov 15;19(11):e3001460. Epub 2021 Nov 15.

Department of Ecology and Evolutionary Biology, Yale University, New Haven, Connecticut, United States of America.

A vast range of research applications in biodiversity sciences requires integrating primary species, genetic, or ecosystem data with other environmental data. This integration requires a consideration of the spatial and temporal scale appropriate for the data and processes in question. But a versatile and scale flexible environmental annotation of biodiversity data remains constrained by technical hurdles. Existing tools have streamlined the intersection of occurrence records with gridded environmental data but have remained limited in their ability to address a range of spatial and temporal grains, especially for large datasets. We present the Spatiotemporal Observation Annotation Tool (STOAT), a cloud-based toolbox for flexible biodiversity-environment annotations. STOAT is optimized for large biodiversity datasets and allows user-specified spatial and temporal resolution and buffering in support of environmental characterizations that account for the uncertainty and scale of data and of relevant processes. The tool offers these services for a growing set of near global, remotely sensed, or modeled environmental data, including Landsat, MODIS, EarthEnv, and CHELSA. STOAT includes a user-friendly, web-based dashboard that provides tools for annotation task management and result visualization, linked to Map of Life, and a dedicated R package (rstoat) for programmatic access. We demonstrate STOAT functionality with several examples that illustrate phenological variation and spatial and temporal scale dependence of environmental characteristics of birds at a continental scale. We expect STOAT to facilitate broader exploration and assessment of the scale dependence of observations and processes in ecology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1371/journal.pbio.3001460DOI Listing
November 2021

Identification of driver genes for critical forms of COVID-19 in a deeply phenotyped young patient cohort.

Sci Transl Med 2021 Oct 26:eabj7521. Epub 2021 Oct 26.

Laboratoire d'ImmunoRhumatologie Moléculaire, plateforme GENOMAX, INSERM UMR_S 1109, Faculté de Médecine, Institut Thématique Interdisciplinaire (ITI) de Médecine de Précision de Strasbourg, Transplantex NG, Université de Strasbourg; 67085 Strasbourg, France.

[Figure: see text].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1126/scitranslmed.abj7521DOI Listing
October 2021

Setup Accuracy in Craniospinal Irradiation: Implications for Planning Treatment Volume Margins.

Adv Radiat Oncol 2021 Sep-Oct;6(5):100747. Epub 2021 Jul 4.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California.

Purpose: Craniospinal irradiation (CSI) using tomotherapy has advantages over standard 3-dimensional techniques. However, there is a paucity of published data on craniospinal setup reproducibility to guide appropriate planning treatment volume (PTV) margins. We sought to evaluate the setup accuracy of patients undergoing CSI to optimize PTV margins.

Methods And Materials: We measured residual setup deviation between simulation computed tomography (CT) and daily megavoltage CT after couch shifts made by therapists after megavoltage CT-based image registration for 10 patients who completed CSI at our institution. Translational displacement values were recorded at the sella, top of T1, and top of L5 in the anteroposterior (AP) and lateral planes. Systematic and random error were calculated from displacement values. Using score analysis, we calculated minimal PTV margins to encompass 90% of recorded fractions at each level. We evaluated whether patient characteristics predict for increased setup error using standard statistical techniques.

Results: The mean setup deviation in the AP plane across all treatments was 2.49, 3.40, and 3.83 mm at the sella, T1, and L5, respectively. Mean lateral setup error was 2.86, 4.02, and 5.46 mm at the sella, T1, and L5, respectively. Systematic error ranged from 0.75 to 1.01 mm at the sella, 1.09 to 1.37 mm at T1, and 1.30 to 1.50 mm at L5. Random error ranged from 1.35 to 1.41 mm at the sella, 1.48 to 1.73 mm at T1, and 2.26 to 2.37 mm at L5. The minimum margin to cover 90% of the treatments was 6.4, 8.2, and 10.5 mm at the sella, T1, and L5, respectively. There appeared to be a correlation between older age and lateral setup error in the L spine approaching statistical significance (R, 0.629;  = .052).

Conclusions: Setup error increases in the caudal direction of the spine and is greater in the lateral plane compared with the AP plane. We recommend a PTV margin of 5 to 7 mm in the brain and 10 mm in the spine.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.adro.2021.100747DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8498716PMC
July 2021

An Adversarial Deep-Learning-Based Model for Cervical Cancer CTV Segmentation With Multicenter Blinded Randomized Controlled Validation.

Front Oncol 2021 19;11:702270. Epub 2021 Aug 19.

Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

Purpose: To propose a novel deep-learning-based auto-segmentation model for CTV delineation in cervical cancer and to evaluate whether it can perform comparably well to manual delineation by a three-stage multicenter evaluation framework.

Methods: An adversarial deep-learning-based auto-segmentation model was trained and configured for cervical cancer CTV contouring using CT data from 237 patients. Then CT scans of additional 20 consecutive patients with locally advanced cervical cancer were collected to perform a three-stage multicenter randomized controlled evaluation involving nine oncologists from six medical centers. This evaluation system is a combination of objective performance metrics, radiation oncologist assessment, and finally the head-to-head Turing imitation test. Accuracy and effectiveness were evaluated step by step. The intra-observer consistency of each oncologist was also tested.

Results: In stage-1 evaluation, the mean DSC and the 95HD value of the proposed model were 0.88 and 3.46 mm, respectively. In stage-2, the oncologist grading evaluation showed the majority of AI contours were comparable to the GT contours. The average CTV scores for AI and GT were 2.68 2.71 in week 0 ( = .206), and 2.62 2.63 in week 2 ( = .552), with no significant statistical differences. In stage-3, the Turing imitation test showed that the percentage of AI contours, which were judged to be better than GT contours by ≥5 oncologists, was 60.0% in week 0 and 42.5% in week 2. Most oncologists demonstrated good consistency between the 2 weeks ( > 0.05).

Conclusions: The tested AI model was demonstrated to be accurate and comparable to the manual CTV segmentation in cervical cancer patients when assessed by our three-stage evaluation framework.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fonc.2021.702270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8417437PMC
August 2021

Design optimization of a cardiovascular stent with application to a balloon expandable prosthetic heart valve.

Mater Des 2021 Nov 10;209. Epub 2021 Jul 10.

Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian - Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.

A cardiovascular stent design optimization method is proposed with application to a pediatric balloon-expandable prosthetic heart valve. The prosthetic valved conduit may be expanded to a larger permanent diameter via subsequent transcatheter balloon dilation procedures. While multiple expandable prosthetic heart valves are currently at different stages of development, this work is focused on one particular design in which a stent is situated inside of an expandable polymeric valved conduit. Since the valve and conduit must be joined with a robust manufacturing technique, a polymeric glue layer is inserted between the two, which results in radial retraction of the valved region after expansion. Design of an appropriate stent is proposed to counteract this phenomenon and maintain the desired permanent diameter throughout the device after a single non-compliant balloon dilation procedure. The finite element method is used to compute performance metrics related to the permanent expansion diameter and required radial force. Additionally, failure due not only to high cycle fatigue but also due to ductile fracture is incorporated into the design study through the use of an existing ductile fracture criterion for metals. Surrogate models are constructed with the results of the high fidelity simulations and are subsequently used to numerically obtain a set of Pareto-optimal stent designs. Finally, a single design is identified by optimizing a normalized aggregate objective function with equal weighting of all design objectives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.matdes.2021.109977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8336925PMC
November 2021

Quantum processor-inspired machine learning in the biomedical sciences.

Patterns (N Y) 2021 Jun 28;2(6):100246. Epub 2021 Apr 28.

Computational Statistics and Bioinformatics Group, Genuity AI Research Institute, Genuity Science, 90 Canal Street, Suite 120, Boston, MA 02114, USA.

Recent advances in high-throughput genomic technologies coupled with exponential increases in computer processing and memory have allowed us to interrogate the complex molecular underpinnings of human disease from a genome-wide perspective. While the deluge of genomic information is expected to increase, a bottleneck in conventional high-performance computing is rapidly approaching. Inspired by recent advances in physical quantum processors, we evaluated several unconventional machine-learning (ML) strategies on actual human tumor data, namely "Ising-type" methods, whose objective function is formulated identical to simulated annealing and quantum annealing. We show the efficacy of multiple Ising-type ML algorithms for classification of multi-omics human cancer data from The Cancer Genome Atlas, comparing these classifiers to a variety of standard ML methods. Our results indicate that Ising-type ML offers superior classification performance with smaller training datasets, thus providing compelling empirical evidence for the potential future application of unconventional computing approaches in the biomedical sciences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.patter.2021.100246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212142PMC
June 2021

Factors predictive of 90-day mortality after surgical resection for oral cavity cancer: Development of a recursive partitioning analysis for risk stratification.

Head Neck 2021 09 19;43(9):2731-2739. Epub 2021 May 19.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California, USA.

Background: Factors that influence postoperative mortality (POM) have been identified, but a predictive model to guide clinicians treating oral cavity cancer (OCC) has not been well established.

Methods: Patients with OCC undergoing upfront surgical resection were included. Primary outcome was 90-day POM (90dPOM).

Results: 33 845 were identified using the National Cancer Database. Rate of 90dPOM was 3.2%. Predictors of higher 90dPOM include older age, higher comorbidity scores, nonprivate insurance, lower income, treatment in an academic facility, higher T- and N-classification, radical excision, and presence of positive margins. On RPA, two high-risk (90dPOM > 10%) patient subsets were identified: patients ≥80 years of age with T3-4 disease and patients <80 years, with any comorbidity and T3-4, N2-3 disease.

Conclusions: We identified a subset of patients in this cohort who are at high risk for 90dPOM. These patients may warrant additional perioperative and postoperative monitoring in addition to better preoperative assessment and screening.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.26740DOI Listing
September 2021

Engineering complex communities by directed evolution.

Nat Ecol Evol 2021 07 13;5(7):1011-1023. Epub 2021 May 13.

Department of Ecology & Evolutionary Biology, Yale University, New Haven, CT, USA.

Directed evolution has been used for decades to engineer biological systems at or below the organismal level. Above the organismal level, a small number of studies have attempted to artificially select microbial ecosystems, with uneven and generally modest success. Our theoretical understanding of artificial ecosystem selection is limited, particularly for large assemblages of asexual organisms, and we know little about designing efficient methods to direct their evolution. Here, we have developed a flexible modelling framework that allows us to systematically probe any arbitrary selection strategy on any arbitrary set of communities and selected functions. By artificially selecting hundreds of in silico microbial metacommunities under identical conditions, we first show that the main breeding methods used to date, which do not necessarily let communities reach their ecological equilibrium, are outperformed by a simple screen of sufficiently mature communities. We then identify a range of alternative directed evolution strategies that, particularly when applied in combination, are well suited for the top-down engineering of large, diverse and stable microbial consortia. Our results emphasize that directed evolution allows an ecological structure-function landscape to be navigated in search of dynamically stable and ecologically resilient communities with desired quantitative attributes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41559-021-01457-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263491PMC
July 2021

Floor-vibration VR: Mitigating Cybersickness Using Whole-body Tactile Stimuli in Highly Realistic Vehicle Driving Experiences.

IEEE Trans Vis Comput Graph 2021 05 15;27(5):2669-2680. Epub 2021 Apr 15.

This work addresses cybersickness, a major barrier to successful long-exposure immersive virtual reality (VR) experiences since user discomfort frequently leads to prematurely ending such experiences. Starting from sensory conflict theory, we posit that if a vibrating floor delivers vestibular stimuli that minimally match the vibration characteristics of a scenario, the size of the conflict between the visual and vestibular senses will be reduced and, thus, the incidence and/or severity of cybersickness will also be reduced. We integrated a custom-built, computer-controlled vibrating floor in our VR system. To evaluate the system, we implemented a realistic off-road vehicle driving simulator in which participants rode multiple laps as passengers on an off-road course. We programmed the floor to generate vertical vibrations similar to those experienced in real off-road vehicle travel. The scenario and driving conditions were designed to be cybersickness-inducing for users in both the Vibration and No-vibration conditions. We collected subjective and objective data for variables previously shown to be related to levels of cybersickness or presence. These included presence and simulator sickness questionnaires (SSQ), self-rated discomfort levels, and the physiological signals of heart rate, galvanic skin response (GSR), and pupil size. Comparing data between participants in the Vibration group (N=11) to the No-Vibration group (N=11), we found that Delta-SSQ Oculomotor response and the GSR physiological signal, both known to be positively correlated with cybersickness, were significantly lower (with large effect sizes) for the Vibration group. Other variables differed between groups in the same direction, but with trivial or small effect sizes. The results indicate that the floor vibration significantly reduced some measures of cybersickness.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1109/TVCG.2021.3067773DOI Listing
May 2021

Disparate outcomes in nonsmall cell lung cancer by immigration status.

Cancer Med 2021 04 18;10(8):2660-2667. Epub 2021 Mar 18.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA.

Objective: The purpose of this study was to evaluate overall survival (OS) outcomes by race, stratified by country of origin in patients diagnosed with NSCLC in California.

Methods: We performed a retrospective analysis of nonsmall cell lung cancer (NSCLC) patients diagnosed between 2000 and 2012. Race/ethnicity was defined as White (W), Black (B), Hispanic (H), and Asian (A) and stratified by country of origin (US vs. non-US [NUS]) creating the following patient cohorts: W-US, W-NUS, B-US, B-NUS, H-US, H-NUS, A-US, and A-NUS. Three multivariate models were created: model 1 adjusted for age, gender, stage, year of diagnosis and histology; model 2 included model 1 plus treatment modalities; and model 3 included model 2 with the addition of socioeconomic status, marital status, and insurance.

Results: A total of 68,232 patients were included. Median OS from highest to lowest were: A-NUS (15 months), W-NUS (14 months), A-US (13 months), B-NUS (13 months), H-US (11 months), W-US (11 months), H-NUS (10 months), and B-US (10 months) (p < 0.001). In model 1, B-US had worse OS, whereas A-US, W-NUS, B-NUS, H-NUS, and A-NUS had better OS when compared to W-US. In model 2 after adjusting for receipt of treatment, there was no difference in OS for B-US when compared to W-US. After adjusting for all variables (model 3), all race/ethnicity profiles had better OS when compared to W-US; B-NUS patients had similar OS to W-US.

Conclusion: Foreign-born patients with NSCLC have decreased risk of mortality when compared to native-born patients in California after accounting for treatments received and socioeconomic differences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/cam4.3848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026917PMC
April 2021

A Real-Time Eating Detection System for Capturing Eating Moments and Triggering Ecological Momentary Assessments to Obtain Further Context: System Development and Validation Study.

JMIR Mhealth Uhealth 2020 12 18;8(12):e20625. Epub 2020 Dec 18.

Georgia Institute of Technology, Atlanta, GA, United States.

Background: Eating behavior has a high impact on the well-being of an individual. Such behavior involves not only when an individual is eating, but also various contextual factors such as with whom and where an individual is eating and what kind of food the individual is eating. Despite the relevance of such factors, most automated eating detection systems are not designed to capture contextual factors.

Objective: The aims of this study were to (1) design and build a smartwatch-based eating detection system that can detect meal episodes based on dominant hand movements, (2) design ecological momentary assessment (EMA) questions to capture meal contexts upon detection of a meal by the eating detection system, and (3) validate the meal detection system that triggers EMA questions upon passive detection of meal episodes.

Methods: The meal detection system was deployed among 28 college students at a US institution over a period of 3 weeks. The participants reported various contextual data through EMAs triggered when the eating detection system correctly detected a meal episode. The EMA questions were designed after conducting a survey study with 162 students from the same campus. Responses from EMAs were used to define exclusion criteria.

Results: Among the total consumed meals, 89.8% (264/294) of breakfast, 99.0% (406/410) of lunch, and 98.0% (589/601) of dinner episodes were detected by our novel meal detection system. The eating detection system showed a high accuracy by capturing 96.48% (1259/1305) of the meals consumed by the participants. The meal detection classifier showed a precision of 80%, recall of 96%, and F1 of 87.3%. We found that over 99% (1248/1259) of the detected meals were consumed with distractions. Such eating behavior is considered "unhealthy" and can lead to overeating and uncontrolled weight gain. A high proportion of meals was consumed alone (680/1259, 54.01%). Our participants self-reported 62.98% (793/1259) of their meals as healthy. Together, these results have implications for designing technologies to encourage healthy eating behavior.

Conclusions: The presented eating detection system is the first of its kind to leverage EMAs to capture the eating context, which has strong implications for well-being research. We reflected on the contextual data gathered by our system and discussed how these insights can be used to design individual-specific interventions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/20625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775824PMC
December 2020

Treatment patterns and outcomes for cerebellar glioblastoma in the concomitant chemoradiation era: A National Cancer database study.

J Clin Neurosci 2020 Dec 6;82(Pt A):122-127. Epub 2020 Nov 6.

Department of Neurosurgery, Stanford Medical Center, Palo Alto 94304, CA, USA. Electronic address:

Cerebellar glioblastoma (GB) is much rarer than its supratentorial counterpart, and potentially of different molecular origin. Prior database studies are of limited size and reported on patients who preceded the validation of temozolomide. Thus, we provide an updated population-based analysis of the treatment trends and outcomes since the standardization of GB adjuvant chemoradiation. Patients diagnosed with primary cerebellar and supratentorial GB were identified from the National Cancer Database spanning 2005-2015. Patients were characterized by demographics, extent of resection, and adjuvant chemotherapy or radiation status. Cohorts were primarily and secondarily assessed for overall survival by tumor site and treatment history, respectively. A total of 655 patients with cerebellar GB were identified (0.6%). Cerebellar GB patients, compared to supratentorial GB were more likely to undergo a biopsy or subtotal resection (13.4% vs 9.3% and 16.0% vs 13.4%, p-value < 0.001), and less likely to pursue adjuvant therapy (48.4% vs 52.7%, p-value < 0.001). Overall median survivals were 9.3 and 9.4 months, respectively. On multivariable analysis, gross total resection, radiation, and chemotherapy were found to be predictors of improved overall survival (HR 0.77, p = 0.038; HR 0.67, p < 0.001; and HR = 0.77, p = 0.030, respectively). While many management principles are currently shared between cerebellar and supratentorial GB, aggressive regimens appear less frequently prescribed. Survival continues to match supratentorial outcomes and may benefit from future, systemic guidance by distinguishing molecular features.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2020.10.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738760PMC
December 2020

Plaque morphology in acute symptomatic intracranial atherosclerotic disease.

J Neurol Neurosurg Psychiatry 2020 Nov 25. Epub 2020 Nov 25.

Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China

Background: Intracranial atherosclerotic disease (ICAD) is globally a major ischaemic stroke subtype with high recurrence. Understanding the morphology of symptomatic ICAD plaques, largely unknown by far, may help identify vulnerable lesions prone to relapse.

Methods: We prospectively recruited patients with acute ischaemic stroke or transient ischaemic attack attributed to high-grade ICAD (60%-99% stenosis). Plaque morphological parameters were assessed in three-dimensional rotational angiography, including surface contour, luminal stenosis, plaque length/thickness, upstream shoulder angulation, axial/longitudinal plaque distribution and presence of adjoining branch atheromatous disease (BAD). We compared morphological features of smooth, irregular and ulcerative plaques and correlated them with cerebral ischaemic lesion load downstream in MRI.

Results: Among 180 recruited patients (median age=60 years; 63.3% male; median stenosis=75%), plaque contour was smooth (51 (28.3%)), irregular (101 (56.1%)) or ulcerative (28 (15.6%)). Surface ulcers were mostly at proximal (46.4%) and middle one-third (35.7%) of the lesions. Most (84.4%) plaques were eccentric, and half had their maximum thickness over the distal end. Ulcerative lesions were thicker (medians 1.6 vs 1.3 mm; p=0.003), had steeper upstream shoulder angulation (56.2° vs 31.0; p<0.001) and more adjoining BAD (83.3% vs 57.0%; p=0.033) than non-ulcerative plaques. Ulcerative plaques were significantly associated with coexisting acute and chronic infarcts downstream (35.7% vs 12.5%; adjusted OR 4.29, 95% CI 1.65 to 11.14, p=0.003). Sensitivity analyses in patients with anterior-circulation ICAD lesions showed similar results in the associations between the plaque types and infarct load.

Conclusions: Ulcerative intracranial atherosclerotic plaques were associated with vulnerable morphological features and had a higher cumulative infarct load downstream.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/jnnp-2020-325027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958085PMC
November 2020

Growth of the Social #RadOnc Network on Twitter.

Pract Radiat Oncol 2021 May-Jun;11(3):e263-e266. Epub 2020 Sep 28.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California. Electronic address:

Purpose: Twitter is an increasingly popular social media platform within the health care community. The objective of this analysis is to characterize the profile of radiation oncology-related tweets and Twitter users over the past 6 years.

Methods And Materials: Using the web-based social media analytics platform Symplur Signals, we filtered tweets containing at least 1 of the following hashtags or key words: #radonc, #radiationoncology, "rad onc," or "radiation oncology." We evaluated radiation oncology-related Twitter activity between October 2014 and March 2020 for tweet frequency, tweet content, and individuals or groups posting tweets. We identified the most influential Twitter users contributing to radiation oncology-related tweets.

Results: From 2014 to 2020, the quarterly volume of radiation oncology-related tweets increased from 5027 to 29,763. Physicians contributed the largest growth in tweet volume. Academic radiation oncologists comprise 60% of the most influential Twitter accounts responsible for radiation oncology-related content. The number of radiation-oncology resident physicians on Twitter increased from 25 to 328 over the past 6 years, and 20% of radiation-oncology residency programs have a Twitter account. Seventy-one percent of radiation oncology-related tweets generated direct communication via mentions, and 59% of tweets contain links to external sources, including scientific articles.

Conclusions: The number of physicians contributing radiation oncology-related Twitter content has increased significantly in recent years. Academic radiation oncologists are the primary influencers of radiation oncology-related Twitter activity. Twitter is used by radiation oncologists to both professionally network and discuss findings related to the field. There remains the opportunity for radiation oncologists to broaden their audience on Twitter to encompass a more diverse community, including patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.prro.2020.09.008DOI Listing
August 2021

External beam radiation and brachytherapy boost at different facilities is associated with increased treatment delays in cervical cancer.

Int J Gynecol Cancer 2020 10 14;30(10):1505-1512. Epub 2020 Sep 14.

Radiation Oncology, City of Hope Medical Center, Duarte, California, USA

Introduction: Due to variation in facility expertise and capabilities, patients commonly complete external beam radiation therapy at one facility and brachytherapy boost at another. We evaluated the association of external beam radiation therapy and brachytherapy at the same facility versus different facilities with treatment delays and survival.

Methods: Patients receiving definitive external beam radiation therapy and brachytherapy for non-metastatic cervical cancer from 2004 to 2015 were identified in the National Cancer Database. Treatment delays were classified based on published thresholds: a course of >56 days was considered delayed, >65 days moderately delayed, and >77 days severely delayed. Fisher's exact test and logistic regression were used to evaluate the association of same facility versus different facilities with treatment delays and predictors of same facility versus different facility treatment.

Results: We identified 23 911 patients meeting the inclusion criteria at a median follow-up of 39.7 months (IQR 21.0-72.6 months), with 17 391 patients (72.7%) receiving same facility treatment and 6520 patients (27.3%) receiving different facility treatment. Any treatment delay was found in 49.3% of same facility treatments versus 51.9% of different facility treatments (p<0.001); moderate or worse delays in 24.8% of same facility versus 29.4% of different facility treatments (p<0.001); severe treatment delays in 11.3% of same facility versus 15.5% of different facility treatments (p<0.001). Receipt of same facility versus different facility treatment was independently associated with treatment delays (OR 1.28, 95% CI 1.20 to 1.37; p<0.001). Both treatment delays, particularly moderate delays (HR 1.20, 95% CI 1.13 to 1.28; p<0.001) and severe delays (HR 1.32, 95% CI 1.24 to 1.41; p<0.001), and different facility treatments (HR 1.11, 95% CI 1.06 to 1.16; p<0.001) were associated with worse survival.

Conclusions: Delivery of external beam radiation therapy and brachytherapy at different facilities was associated with treatment delays and worse survival. Our findings underscore the importance of care coordination in cervical cancer management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/ijgc-2020-001700DOI Listing
October 2020

Frontline Management of Epithelial Ovarian Cancer-Combining Clinical Expertise with Community Practice Collaboration and Cutting-Edge Research.

J Clin Med 2020 Sep 1;9(9). Epub 2020 Sep 1.

Department of Surgical Oncology, City of Hope National Medical Center, Duarte, CA 91010, USA.

Epithelial ovarian cancer (EOC) is the most common histology of ovarian cancer defined as epithelial cancer derived from the ovaries, fallopian tubes, or primary peritoneum. It is the fifth most common cause of cancer-related death in women in the United States. Because of a lack of effective screening and non-specific symptoms, EOC is typically diagnosed at an advanced stage (FIGO stage III or IV) and approximately one third of patients have malignant ascites at initial presentation. The treatment of ovarian cancer consists of a combination of cytoreductive surgery and systemic chemotherapy. Despite the advances with new cytotoxic and targeted therapies, the five-year survival rate for all-stage EOC in the United States is 48.6%. Delivery of up-to-date guideline care and multidisciplinary team efforts are important drivers of overall survival. In this paper, we review our frontline management of EOC that relies on a multi-disciplinary approach drawing on clinical expertise and collaboration combined with community practice and cutting edge clinical and translational research. By optimizing partnerships through team medicine and clinical research, we combine our cancer center clinical expertise, community practice partnership, and clinical and translational research to understand the biology of this deadly disease, advance therapy and connect our patients with the optimal treatment that offers the best possible outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jcm9092830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565288PMC
September 2020

Machine Learning-Based Interpretation and Visualization of Nonlinear Interactions in Prostate Cancer Survival.

JCO Clin Cancer Inform 2020 07;4:637-646

Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA.

Purpose: Shapley additive explanation (SHAP) values represent a unified approach to interpreting predictions made by complex machine learning (ML) models, with superior consistency and accuracy compared with prior methods. We describe a novel application of SHAP values to the prediction of mortality risk in prostate cancer.

Methods: Patients with nonmetastatic, node-negative prostate cancer, diagnosed between 2004 and 2015, were identified using the National Cancer Database. Model features were specified a priori: age, prostate-specific antigen (PSA), Gleason score, percent positive cores (PPC), comorbidity score, and clinical T stage. We trained a gradient-boosted tree model and applied SHAP values to model predictions. Open-source libraries in Python 3.7 were used for all analyses.

Results: We identified 372,808 patients meeting the inclusion criteria. When analyzing the interaction between PSA and Gleason score, we demonstrated consistency with the literature using the example of low-PSA, high-Gleason prostate cancer, recently identified as a unique entity with a poor prognosis. When analyzing the PPC-Gleason score interaction, we identified a novel finding of stronger interaction effects in patients with Gleason ≥ 8 disease compared with Gleason 6-7 disease, particularly with PPC ≥ 50%. Subsequent confirmatory linear analyses supported this finding: 5-year overall survival in Gleason ≥ 8 patients was 87.7% with PPC < 50% versus 77.2% with PPC ≥ 50% ( < .001), compared with 89.1% versus 86.0% in Gleason 7 patients ( < .001), with a significant interaction term between PPC ≥ 50% and Gleason ≥ 8 ( < .001).

Conclusion: We describe a novel application of SHAP values for modeling and visualizing nonlinear interaction effects in prostate cancer. This ML-based approach is a promising technique with the potential to meaningfully improve risk stratification and staging systems.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/CCI.20.00002DOI Listing
July 2020

Dosimetric Predictors of Genitourinary Toxicity From a Phase I Trial of Prostate Bed Stereotactic Body Radiation Therapy.

Pract Radiat Oncol 2021 Jan-Feb;11(1):e90-e97. Epub 2020 Jun 18.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California. Electronic address:

Purpose: Our purpose was to analyze dose-volume parameters associated with genitourinary (GU) toxicity from a phase I clinical trial of prostate bed stereotactic body radiation therapy.

Methods And Materials: Patients were treated in escalating dose levels of 35, 40, and 45 Gy, over 5 fractions. Data from all 26 patients enrolled in the protocol were analyzed using multiple dose-volume cut points for multiple GU organs at risk. Univariate logistical regression and Fisher exact test were used to assess statistical significance associated with incidence of toxicity.

Results: The median follow-up was 36 months for all patients. Acute GU toxicity was mild and resolved spontaneously. Eight out of 26 patients (30.7%) developed late GU toxicity of grade 2 or higher. Two patients developed grade 3 ureteral stenosis, 1 in the 35 Gy arm and the other in the 45 Gy arm. Three patients developed grade 2 or higher hematuria/cystitis, and 3 developed grade 2 or higher incontinence. Incidence of grade 3 ureteral stenosis was related to the absolute volume of bladder wall receiving greater than 20, 25, and 30 Gy (P < .01). Grade 2 cystitis and hematuria were related to the volume of bladder wall receiving 20 Gy less than 34% and 35 Gy less than 25% (18.8% vs 60% and 23.8% vs 80%, respectively, P < .05). Incontinence was related to mean urethral dose less than 35 Gy and 25 Gy (4.3% vs 66.7% and 0% vs 37.5%, respectively, P < .05) and volume of urethra receiving 35 Gy less than 24% (8.3% vs 50%, P < .05).

Conclusions: This is the first analysis to report dose-volume thresholds associated with late GU toxicity in patients receiving prostate bed stereotactic body radiation therapy. We recommend limiting the bladder wall receiving 25 Gy to less than 18 cubic centimeters to reduce the risk for late grade 3 ureteral stenosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.prro.2020.06.004DOI Listing
August 2021

Radiation Oncology Alternative Payment Model (APM): An Introduction and Primer for the Proposed Rule for Practices and Providers.

Pract Radiat Oncol 2021 Jan-Feb;11(1):e22-e29. Epub 2020 May 16.

Department of Radiation Oncology, City of Hope Medical Center, Duarte, California. Electronic address:

Purpose: The Radiation Oncology Alternative Payment Model (RO-APM) is an alternative payment model under which Medicare patients would be reimbursed using an episode-based payment schema rather than the current fee-for-service schema. The Center for Medicare and Medicaid Services Innovation Center has published a proposed rule for the RO-APM. However, there is no accessible resource that summarizes information about the proposed rule in an easily understandable form.

Methods And Materials: Information regarding the RO-APM was accessed through the Center for Medicare and Medicaid Services Innovation Center website and listening sessions and review of the proposed rule. We summarize the most important information regarding the background, mechanics, and timeline of the proposed rule to facilitate wider understanding in the radiation oncology community and answer commonly held questions.

Results: The proposed rule for the RO-APM would cover 40% and have widespread effect on the future of radiation oncology. We provide a primer that summarizes important information regarding the rule for practices and providers.

Conclusion: The proposed RO-APM will change the landscape of radiation oncology reimbursement. Understanding the implications of the model will be key to maintining a successful practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.prro.2020.04.011DOI Listing
August 2021

Clinical and pathological characterization of FLNC-related myofibrillar myopathy caused by founder variant c.8129G>A in Hong Kong Chinese.

Clin Genet 2020 05 23;97(5):747-757. Epub 2020 Feb 23.

Department of Pathology, Queen Elizabeth Hospital, Hong Kong.

FLNC-related myofibrillar myopathy could manifest as autosomal dominant late-onset slowly progressive proximal muscle weakness; involvements of cardiac and/or respiratory functions are common. We describe 34 patients in nine families of FLNC-related myofibrillar myopathy in Hong Kong ethnic Chinese diagnosed over the last 12 years, in whom the same pathogenic variant c.8129G>A (p.Trp2710*) was detected. Twenty-six patients were symptomatic when diagnosed; four patients died of pneumonia and/or respiratory failure. Abnormal amorphous material or granulofilamentous masses were detected in half of the cases, with mitochondrial abnormalities noted in two-thirds. We also show by haplotype analysis the founder effect associated with this Hong Kong variant, which might have occurred 42 to 71 generations ago or around Tang and Song dynasties, and underlain a higher incidence of myofibrillar myopathy among Hong Kong Chinese. The late-onset nature and slowly progressive course of the highly penetrant condition could have significant impact on the family members, and an early diagnosis could benefit the whole family. Considering another neighboring founder variant in FLNC in German patients, we advocate development of specific therapies such as chaperone-based or antisense oligonucleotide strategies for this particular type of myopathy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/cge.13715DOI Listing
May 2020

Is day 7 culture necessary for in vitro fertilization of cryopreserved/warmed human oocytes?

Reprod Biol Endocrinol 2020 Jan 18;18(1). Epub 2020 Jan 18.

Prelude-Houston Fertility Laboratory, Houston Fertility Institute, 2500 Fondren Rd., Suite 350, Houston, TX, 77063, USA.

Background: Human embryos are usually cultured to blastocyst stage by Day 5 or 6 after insemination. However, some embryos grow slowly and reach blastocyst stage at Day 7. Acceptable live birth rates have been reported after transfer of Day 7 blastocysts resulted from fresh oocyte in vitro fertilization (IVF). It is unknown whether an extended embryo culture to Day 7 is necessary for cryopreserved oocyte IVF to obtain more transferrable blastocysts.

Methods: In this study, 455 oocytes from 57 cycles were warmed, inseminated, and the resulting embryos were cultured by Day 7 to examine blastocyst development after extended culture. Fifty one blastocysts from 16 cycles were biopsied to examine embryo aneuploidies.

Results: It was found that 35.1% of the cycles had Day 7 blastocysts, and 3.5% of the cycles had only Day 7 blastocysts. Day 7 blastocysts accounted for 15.6% of total blastocysts. The proportion of top quality of blastocysts was lower at Day 7 than at Day 5 or 6. However, no differences were observed on aneuploid blastocyst rates among Days 5, 6 and 7. Similar clinical pregnancy, ongoing pregnancy and embryo implantation rates were obtained after Day 7 blastocyst transfer as compared with Day 5 or 6 blastocyst transfer.

Conclusion: These results indicate that embryos from oocyte warming cycles should be cultured to Day 7 if they do not reach to blastocyst stage by Day 6 so that number of usable blastocysts can be increased.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12958-020-0565-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6969436PMC
January 2020

Patterns of care and treatment outcomes in patients age 80 or older with non-metastatic pancreatic cancer.

J Geriatr Oncol 2020 05 26;11(4):652-659. Epub 2019 Dec 26.

Department of Radiation Oncology, City of Hope Medical Center, Duarte, CA, United States of America. Electronic address:

Introduction: Older adults are underrepresented in landmark trials that determine treatment guidelines for pancreatic cancer. We used the National Cancer Database (NCDB) to compare treatment patterns and outcomes in stage I-III pancreatic cancer between older adult patients, defined as age 80 or older, to patients younger than 80.

Material And Methods: We identified 140,678 patients in the NCDB diagnosed with pancreatic cancer from 2004 to 2015. Patients with metastatic disease or non-adenocarcinoma histologies were excluded. Descriptive statistics comparing patients age 80+ and age <80 were generated. Logistic regression was used to evaluate predictors of cancer-directed therapy receipt (defined as receipt of chemotherapy, radiation, or surgery) in older patients, and Cox proportional hazards modeling was performed to evaluate survival in the older cohort.

Results: We identified 140,678 patients with non-metastatic pancreatic cancer, of which 23,395 patients (16.6%) were 80 or older. Among older patients, 44.5% of patients received cancer-directed therapy compared to 78.7% among other patients (p < .001). Older patients had worse 2-year survival at 11.3% versus 27.5% for younger (p < .001). 2-year survivorship decreased further in older patients who received no cancer-directed treatment, at 4.7% compared with 19.5% for older patients receiving treatment (p < .001). After propensity score matching, cancer-directed treatment remained associated with improved survival for older patients (hazard ratio 0.42; 95% confidence interval 0.41-0.43; p < .001).

Discussion: Rates of cancer-directed therapy were low in patients age 80+, with 55.5% receiving no therapy. Cancer-directed treatment was associated with an overall survival benefit. Future trials are needed to define optimal treatment paradigms in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jgo.2019.12.006DOI Listing
May 2020

Resident experience in brachytherapy: An analysis of Accreditation Council for Graduate Medical Education case logs for intracavitary and interstitial brachytherapy from 2007 to 2018.

Brachytherapy 2020 Nov - Dec;19(6):718-724. Epub 2019 Dec 12.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA. Electronic address:

Purpose: We sought to characterize temporal trends of radiation oncology resident-reported case experience with intracavitary brachytherapy (ICBT) and interstitial brachytherapy (ISBT).

Methods And Materials: Summarized, deidentified case logs for graduating radiation oncology residents (GRORs) between 2007 and 2018 were obtained from the Accreditation Council for Graduate Medical Education national summary data report. Cases were subdivided based on the site of treatment. Analysis of variance was used to determine differences, and strength of association was evaluated using the Pearson correlation.

Results: The number of GRORs increased by 66% from 114 in 2007 to 189 in 2018 (p < 0.001). Average number of gynecologic ICBT cases per GROR increased, from 39.6 in 2007 to 48.7 in 2018 (p < 0.005). Average number of ISBT cases per GROR decreased, from 34.5 to 20.6 (p < 0.001), due to decreasing prostate volume, from 21.5 to 12 (p < 0.001). Experience with gynecologic ISBT cases remained low at an average of 4.5 cases per year.

Conclusions: The average number of ICBT cases per GROR has increased, although this does not differentiate between cylinder and tandem-based insertions currently. There has been a steady decline in ISBT experience. These findings may have implications for the development of Accreditation Council for Graduate Medical Education case minimums for residency programs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.brachy.2019.10.006DOI Listing
May 2021

Radiation Therapy for Surgically Resected Brain Metastasis: What Is Your Approach?

Int J Radiat Oncol Biol Phys 2019 12;105(5):938-939

Department of Radiation Oncology, City of Hope Medical Center, Duarte, California. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijrobp.2018.04.047DOI Listing
December 2019

Impact of Surgical Resection on Survival Outcomes After Chemoradiotherapy in Anal Adenocarcinoma.

J Natl Compr Canc Netw 2019 10;17(10):1203-1210

Department of Radiation Oncology.

Background: Anal adenocarcinoma is a rare malignancy with a poor prognosis, and no randomized data are available to guide management. Prior retrospective analyses offer differing conclusions on the benefit of surgical resection after chemoradiotherapy (CRT) in these patients. We used the National Cancer Database (NCDB) to analyze survival outcomes in patients undergoing CRT with and without subsequent surgical resection.

Methods: Patients with adenocarcinoma of the anus diagnosed in 2004 through 2015 were identified using the NCDB. Patients with metastatic disease and survival <90 days were excluded. We analyzed patients receiving CRT and stratified by receipt of surgical resection. Logistic regression was used to evaluate predictors of use of surgery and to form a propensity score-matched cohort. Overall survival (OS) was compared between treatment strategies using Cox proportional hazards regression.

Results: We identified 1,747 patients with anal adenocarcinoma receiving CRT, of whom 1,005 (58%) received surgery. Predictors of increased receipt of surgery included age <65 years, private insurance, overlapping involvement of the anus and rectum, N0 disease, and external-beam radiation dose ≥4,000 cGy. With a median follow-up of 3.5 years, 5-year OS was 61.1% in patients receiving CRT plus surgery compared with 39.8% in patients receiving CRT alone (log-rank P<.001). In multivariate analysis, surgery was associated with significantly improved OS (hazard ratio, -0.59; 95% CI, 0.50-0.68; P<.001). This survival benefit persisted in a propensity score-matched cohort (log-rank P<.001).

Conclusions: In the largest series of anal adenocarcinoma cases to date, treatment with CRT followed by surgery was associated with a significant survival benefit compared with CRT alone in propensity score-matching analysis. Our findings support national guideline recommendations of neoadjuvant CRT followed by resection for patients with anal adenocarcinoma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.6004/jnccn.2019.7309DOI Listing
October 2019

Factors predicting for patient refusal of head and neck cancer therapy.

Head Neck 2020 01 4;42(1):33-42. Epub 2019 Oct 4.

Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California.

Background: The purpose of this study was to evaluate the national rate of treatment refusal in head and neck cancer (HNC).

Methods: The National Cancer Database was queried for nonmetastatic squamous cell carcinoma of the head and neck. Oncologic therapy referred to receipt of surgery, radiotherapy, or chemotherapy.

Results: Compared to the 230 424 patients who received treatment, 2965 (1.3%) were reported to have refused definitive therapy. Predictors included older age, female sex, African-American/other race, nonprivate insurance, greater comorbidities, more advanced disease, and residence closer to the treating facility (P < .05). Patients with a prior history of cancer, Hispanic race, those treated at academic centers, and those from higher income counties were less likely to refuse therapy (P < .05). Patients who refused definitive therapy experienced poorer survival (median 79.1 vs 8.7 months, P < .001).

Conclusions: Refusing oncologic therapy is relatively rare in HNC and appears to be multifocal in nature.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/hed.25966DOI Listing
January 2020

Mechanical considerations for polymeric heart valve development: Biomechanics, materials, design and manufacturing.

Biomaterials 2019 12 17;225:119493. Epub 2019 Sep 17.

Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, New-York Presbyterian - Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA. Electronic address:

The native human heart valve leaflet contains a layered microstructure comprising a hierarchical arrangement of collagen, elastin, proteoglycans and various cell types. Here, we review the various experimental methods that have been employed to probe this intricate microstructure and which attempt to elucidate the mechanisms that govern the leaflet's mechanical properties. These methods include uniaxial, biaxial, and flexural tests, coupled with microstructural characterization techniques such as small angle X-ray scattering (SAXS), small angle light scattering (SALS), and polarized light microscopy. These experiments have revealed complex elastic and viscoelastic mechanisms that are highly directional and dependent upon loading conditions and biochemistry. Of all engineering materials, polymers and polymer-based composites are best able to mimic the tissue-level mechanical behavior of the native leaflet. This similarity to native tissue permits the fabrication of polymeric valves with physiological flow patterns, reducing the risk of thrombosis compared to mechanical valves and in some cases surpassing the in vivo durability of bioprosthetic valves. Earlier work on polymeric valves simply assumed the mechanical properties of the polymer material to be linear elastic, while more recent studies have considered the full hyperelastic stress-strain response. These material models have been incorporated into computational models for the optimization of valve geometry, with the goal of minimizing internal stresses and improving durability. The latter portion of this review recounts these developments in polymeric heart valves, with a focus on mechanical testing of polymers, valve geometry, and manufacturing methods.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.biomaterials.2019.119493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6948849PMC
December 2019

A proposal for a new classification of "unfavorable risk criteria" in patients with stage I endometrial cancer.

Int J Gynecol Cancer 2019 09;29(7):1086-1093

Radiation Oncology, City of Hope Medical Center, Duarte, California, USA

Background: Randomized trials describe differing sets of high-intermediate risk criteria.

Objective: To use the National Cancer Database to compare the impact of radiation therapy in patients with stage I endometrial cancer meeting different criteria, and define a classification of "unfavorable risk."

Methods: Patients with stage I endometrial cancer between January 2010 and December 2014 were identified in the National Cancer Database and stratified into two cohorts: (1) patients meeting Gynecologic Oncology Group (GOG)-99 criteria only for high-intermediate risk, but not Post-Operative Radiation Therapy in Endometrial Carcinoma (PORTEC)-1 criteria and (2) those meeting PORTEC-1 criteria only. High-risk stage I patients with both FIGO stage IB (under FIGO 2009 staging) and grade 3 disease were excluded. In each cohort, propensity score-matched survival analyses were performed. Based on these analyses, we propose a new classification of unfavorable risk. We then analyzed the association of adjuvant radiation with survival, stratified by this classification.

Results: We identified 117,272 patients with stage I endometrial cancer. Of these, 11,207 patients met GOG-99 criteria only and 5,920 patients met PORTEC-1 criteria only. After propensity score matching, adjuvant radiation therapy improved survival (HR=0.73; 95% CI 0.60 to 0.89; p=0.002) in the GOG-99 only cohort. However, there was no benefit of adjuvant radiation (HR=0.89; 95% CI 0.69 to 1.14; p=0.355) in the PORTEC-1 only cohort. We, therefore, defined unfavorable risk stage I endometrial cancer as two or more of the following risk factors: lymphovascular invasion, age ≥70, grade 2-3 disease, and FIGO stage IB. Adjuvant radiation improved survival in stage I patients with adverse risk factors (HR=0.74; 95% CI 0.68 to 0.80; p<0.001), but not in other stage I patients (HR=1.02; 95% CI 0.91 to 1.15; p=0.710; p interaction <0.001).

Conclusion: Our study showed that adjuvant radiation was associated with an overall survival benefit in patients meeting GOG-99 criteria only; however, no survival benefit was seen in patients meeting PORTEC-1 criteria only. We propose a definition of unfavorable risk stage I endometrial cancer: ≥2 risk factors from among lymphovascular invasion, age ≥70, grade 2-3 disease, and FIGO stage IB disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/ijgc-2019-000264DOI Listing
September 2019
-->