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The value of low-dose whole thoracic radiation therapy (LD-WTRT) for SARS-CoV-2 (COVID-19) pneumonia is unknown. Should ongoing clinical trials demonstrate that LD-WTRT proves effective for COVID-19 pneumonia recovery, widespread rapid implementation will be helpful globally. Our aim was to outline a pragmatic process for safe and efficient administration of LD-WTRT to patients with COVID-19 pneumonia that could be implemented successfully in a community hospital setting based on participation in the PreVent clinical trial of LD-WTRT. [ABSTRACT FROM AUTHOR]

The role of radiation therapy in metastatic cancer is rapidly evolving with increased understanding of the oligometastatic state and improved technologies to deliver higher doses of radiation with greater precision and avoidance of normal tissues than before. Recent data have demonstrated that the use of stereotactic ablative radiotherapy (SABR) in oligometastatic disease confers a survival benefit. Yet, the current enthusiasm must be balanced with caution. Here we summarize the evidence in favor of SABR for oligometastatic patients as well as the concerns regarding rapid adoption into clinical practice and outline broad principles to guide clinical trials evaluating the role of SABR in oligometastatic disease. As oncologists, we must exercise due diligence and gather the appropriate evidence necessary to 1) understand the oligometastatic disease state and 2) optimize benefit in those patients before broadly offering SABR to all. Any alternative path forward will do our field and our patients a great injustice. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the association between 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) and biochemical and survival outcomes after high-dose radiotherapy (RT) for prostate cancer. Methods and Materials: A total of 1711 men with clinical stage T1–T3 prostate cancer were treated with conformal RT to a median dose of 81 Gy during 1995–2007. Preradiotherapy medication data were available for 1681 patients. Three hundred eighty-two patients (23%) were taking a statin medication at diagnosis and throughout RT. Nine hundred forty-seven patients received a short-course of neoadjuvant and concurrent androgen-deprivation therapy (ADT) with RT. The median follow-up was 5.9 years. Results: The 5- and 8-year PSA relapse-free survival (PRFS) rates for statin patients were 89% and 80%, compared with 83% and 74% for those not taking statins (p = 0.002). In a multivariate analysis, statin use (hazard ratio [HR] 0.69, p = 0.03), National Comprehensive Cancer Network (NCCN) low-risk group, and ADT use were associated with improved PRFS. Only high-risk patients in the statin group demonstrated improvement in PRFS (HR 0.52, p = 0.02). Across all groups, statin use was not associated with improved distant metastasis-free survival (DMFS) (p = 0.51). On multivariate analysis, lower NCCN risk group (p = 0.01) and ADT use (p = 0.005) predicted improved DMFS. Conclusions: Statin use during high-dose RT for clinically localized prostate cancer was associated with a significant improvement in PRFS in high-risk patients. These data suggest that statins have anticancer activity and possibly provide radiosensitization when used in conjunction with RT in the treatment of prostate cancer. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To assess whether statin use improves local control (LC) in patients undergoing organ-preserving trimodality therapy for muscle-invasive bladder cancer. Methods: We retrospectively analyzed the data from 286 patients with muscle-invasive, transitional cell carcinoma of the bladder treated with maximal transurethral resection of the bladder tumor followed by chemoradiotherapy from 1986 to 2003 at the Massachusetts General Hospital. Patients with a complete response after induction chemoradiotherapy received consolidation chemoradiotherapy and those with an incomplete response underwent cystectomy. Of the 286 patients, 35 (12%) were known to be taking a statin during chemoradiotherapy. LC was defined as freedom from the development of muscle-invasive bladder cancer or superficial bladder cancer necessitating cystectomy. Results: The median follow-up time was 2.7 years for all patients and 3.1 years for survivors. The overall 5-year LC rate was 55%. On univariate analysis, tumor stage, completeness of transurethral resection of the bladder tumor, hydronephrosis, chemotherapy type, treatment era, and statin use were significantly associated with LC. The 5-year LC rate for patients taking a statin was 73% versus 52% for patients not taking a statin (P = 0.04). On multivariate analysis incorporating covariates that were statistically significant (P <0.05) on univariate analysis, only chemotherapy with cisplatin (P = 0.02) and the absence of hydronephrosis (P = 0.01) remained significantly associated with LC. Conclusions: Statin use was associated with an improvement in LC on univariate analysis but was not found to be independently associated with LC after controlling for known prognostic factors. The potential beneficial interaction between statin use and chemoradiotherapy in bladder cancer warrants further investigation in a prospective study. [Copyright &y& Elsevier]

Purpose: To assess whether 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, or statins, might enhance the efficacy of neoadjuvant chemoradiation in rectal cancer. Methods and Materials: Between 1996 and 2001, 358 patients with clinically resectable, nonmetastatic rectal cancer underwent surgery at Memorial Sloan-Kettering Cancer Center after neoadjuvant chemoradiation for either locally advanced tumors or low-lying tumors that would require abdominoperineal resection. We excluded 9 patients for radiation therapy dose &#60;45 Gy or if statin use was unknown, leaving 349 evaluable patients. Median radiation therapy dose was 50.4 Gy (range, 45–55.8 Gy), and 308 patients (88%) received 5-flurouracil-based chemotherapy. Medication use, comorbid illnesses, clinical stage as assessed by digital rectal examination and ultrasound, and type of chemotherapy were analyzed for associations with pathologic complete response (pCR), defined as no microscopic evidence of tumor. Fisher’s exact test was used for categoric variables, Mantel-Haenszel test for ordered categoric variables, and logistic regression for multivariate analysis. Results: Thirty-three patients (9%) used a statin, with no differences in clinical stage according to digital rectal examination or ultrasound compared with the other 324 patients. At the time of surgery, 23 nonstatin patients (7%) were found to have metastatic disease, compared with 0% for statin patients. The unadjusted pCR rates with and without statin use were 30% and 17%, respectively (p = 0.10). Variables significant univariately at the p = 0.15 level were entered into a multivariate model, as were nonsteroidal anti-inflammatory drugs (NSAIDs), which were strongly associated with statin use. The odds ratio for statin use on pCR was 4.2 (95% confidence interval, 1.7–12.1; p = 0.003) after adjusting for NSAID use, clinical stage, and type of chemotherapy. Conclusion: In multivariate analysis, statin use is associated with an improved pCR rate after neoadjuvant chemoradiation for rectal cancer. The low prevalence of statin use limits the power to detect a significant difference at a type I error threshold of p = 0.05 in this analysis. Although no definitive conclusions can be drawn on the basis of this retrospective study, the unusually high incidence of pCR after chemoradiation suggests that the use of statins in the treatment of rectal cancer warrants further evaluation. [Copyright &y& Elsevier]

Consistency of nomenclature within radiation oncology is increasingly important as big data efforts and data sharing become more feasible. Automation of radiation oncology workflows depends on standardized contour nomenclature that enables toxicity and outcomes research, while also reducing medical errors and facilitating quality improvement activities. Recommendations for standardized nomenclature have been published in the American Association of Physicists in Medicine (AAPM) report from Task Group 263 (TG-263). Transitioning to TG-263 requires creation and management of structure template libraries and retraining of staff, which can be a considerable burden on clinical resources. Our aim is to develop a program that allows users to create TG-263–compliant structure templates in English, Spanish, or French to facilitate data sharing. Fifty-three premade structure templates were arranged by treated organ based on an American Society for Radiation Oncology (ASTRO) consensus paper. Templates were further customized with common target structures, relevant organs at risk (OARs) (eg, spleen for anatomically relevant sites such as the gastroesophageal junction or stomach), subsite- specific templates (eg, partial breast, whole breast, intact prostate, postoperative prostate, etc) and brachytherapy templates. An informal consensus on OAR and target coloration was also achieved, although color selections are fully customizable within the program. The resulting program is usable on any Windows system and generates template files in practice-specific Digital Imaging and Communications In Medicine (DICOM) or XML formats, extracting standardized structure nomenclature from an online database maintained by members of the TG-263U1, which ensures continuous access to up-to-date templates. We have developed a tool to easily create and name DICOM radiation therapy (DICOM-RT) structures sets that are TG-263–compliant for all planning systems using the DICOM standard. The program and source code are publicly available via GitHub to encourage feedback from community users for improvement and guide further development. [ABSTRACT FROM AUTHOR]

Purpose: Numerous publications during the COVID-19 pandemic recommended the use of hypofractionated radiation therapy. This project assessed aggregate changes in the quality of the evidence supporting these schedules to establish a comprehensive evidence base for future reference and highlight aspects for future study.Methods and Materials: Based on a systematic review of published recommendations related to dose fractionation during the COVID-19 pandemic, 20 expert panelists assigned to 14 disease groups named and graded the highest quality of evidence schedule(s) used routinely for each condition and also graded all COVID-era recommended schedules. The American Society for Radiation Oncology quality of evidence criteria were used to rank the schedules. Process-related statistics and changes in distributions of quality ratings of the highest-rated versus recommended COVID-19 era schedules were described by disease groups and for specific clinical scenarios.Results: From January to May 2020 there were 54 relevant publications, including 233 recommended COVID-19-adapted dose fractionations. For site-specific curative and site-specific palliative schedules, there was a significant shift from established higher-quality evidence to lower-quality evidence and expert opinions for the recommended schedules (P = .022 and P < .001, respectively). For curative-intent schedules, the distribution of quality scores was essentially reversed (highest levels of evidence "pre-COVID" vs "in-COVID": high quality, 51.4% vs 4.8%; expert opinion, 5.6% vs 49.3%), although there was variation in the magnitude of shifts between disease sites and among specific indications.Conclusions: A large number of publications recommended hypofractionated radiation therapy schedules across numerous major disease sites during the COVID-19 pandemic, which were supported by a lower quality of evidence than the highest-quality routinely used dose fractionation schedules. This work provides an evidence-based assessment of these potentially practice-changing recommendations and informs individualized decision-making and counseling of patients. These data could also be used to support radiation therapy practices in the event of second waves or surges of the pandemic in new regions of the world. [ABSTRACT FROM AUTHOR]

Purpose: The “Roach formula” for the risk of pelvic lymph node metastases [(2/3) ∗ PSA + (Gleason score − 6) ∗ 10] was developed in the early prostate-specific antigen (PSA) era. We examined the accuracy of this formula in contemporary patients. Methods: We included men in the Surveillance, Epidemiology, and End Results Registry with a diagnosis of clinical T1c–T4 prostate cancer in 2004 who had a surgical lymph node evaluation, Gleason score (typically from prostatectomy), and baseline PSA level (n = 9,387). Expected and observed rates of node positivity were compared. Results: Ninety-eight percent were clinical T1c/T2, and 97% underwent prostatectomy. Overall, 309 patients (3.29%) had positive lymph nodes. Roach scores overestimated the actual rate of positive lymph nodes in the derivation set by 16-fold for patients with Roach score less than or equal to 10%, by 7-fold for scores greater than 10–20%, and by approximately 2.5-fold for scores greater than 20%. Applying these adjustment factors to Roach scores in the validation data set yielded accurate predictions of risk. For those with Roach score less than or equal to 10%, adjusted expected risk was 0.2% and observed risk was 0.2%. For Roach score greater than 10–20%, adjusted expected risk was 2.0% and observed risk was 2.1%. For Roach score greater than 20–30%, adjusted expected risk was 9.7% and observed risk was 6.5%. For Roach score greater than 30–40%, adjusted expected risk was 13.9% and observed risk was 13.9%. Conclusion: Applied to contemporary patients with mainly T1c/T2 disease, the Roach formula appears to overestimate pelvic lymph node risk. The adjustment factors presented here should be validated by using biopsy Gleason scores and extended lymphadenectomies. [Copyright &y& Elsevier]

Purpose: To evaluate the technique, dosimetry, acute and late toxicity, local control (LC), and overall survival (OS) with the use of computed tomography (CT)-based postmastectomy electron beam therapy (PMEBT) in high-risk patients. Methods and Materials: From 1990 to 2000, 118 patients with pathologic stage I-IIIB breast cancer underwent PMEBT of the chest wall (CW) (n = 3), CW and supraclavicular fossa (SCV) (n = 63), CW, SCV, and internal mammary lymph nodes (IMN) (n = 51), and SCV+IMN (n = 1). Radiation therapy was delivered with an en face electron beam with a custom cutout. Treatment plans were all CT-based. The plans of 16 patients were retrospectively reviewed to analyze dosimetry data. A retrospective chart review was conducted to assess acute and late complications, LC, and OS. Results: At a median follow-up of 43 months, 5-year LC and OS were 91% and 61%, respectively. Sixty-one patients developed acute grade 3-4 skin toxicity, necessitating treatment breaks in 33 patients. Fifteen patients experienced a worsening of lymphedema, and 2 patients developed cardiac injury thought to be unrelated to radiotherapy. No patients developed symptomatic pneumonitis. Dosimetric analysis revealed heart and lung normal tissue complication probabilities of zero. Analysis of other clinically relevant dosimetric parameters revealed PMEBT to be comparable to previously reported techniques. Conclusion: Postmastectomy electron beam therapy is an effective way to deliver radiation to the postmastectomy chest wall and adjacent nodal sites. It offers acceptable acute and late toxicities and a high degree of local control given the high-risk population to which it is offered. [ABSTRACT FROM AUTHOR]

Purpose: Delivering high dose to prostate with external beam radiation has been shown to improve local tumor control. However, it has to be carefully performed to avoid partial target miss and delivering excessive dose to surrounding normal tissues. One way to achieve safe dose escalation is to precisely localize prostate immediately before daily treatment. Therefore, the radiation can be accurately delivered to the target. Once the prostate position is determined with high confidence, planning target volume (PTV) safety margin might be reduced for further reduction of rectal toxicity. A rapid computed tomography (CT)-based online prostate localization method is presented for this purpose.Methods and Materials: Immediately before each treatment session, the patient is immobilized and undergoes a CT scan in the treatment position using a CT scanner situated in the treatment room. At the CT console, posterior, anterior, left, and right extents of the prostate are manually identified on each axial slice. The translational prostate displacements relative to the planned position are estimated by simultaneously fitting these identified extents from this CT scan to a template created from the finely sliced planning CT scan. A total of 106 serial CT scans from 8 prostate cancer patients were performed immediately before treatments and used to retrospectively evaluate the precision of this daily prostate targeting method. The three-dimensional displacement of the prostate with respect to its planned position was estimated.Results: Five axial slices from each treatment CT scan were sufficient to produce a reliable correction when compared with prostate center of gravity (CoG) displacements calculated from physician-drawn contours. The differences (mean ± SD) between these two correction schemes in the right-left (R/L), posterior-anterior (P/A), and superior-inferior (S/I) directions are 0.0 ± 0.4 mm, 0.0 ± 0.7 mm, and −0.4 ± 1.9 mm, respectively. With daily CT extent-fitting correction, 97% of the scans showed that the entire posterior prostate gland was covered by PTV given a margin of 6 mm at the rectum-prostate interface and 10 mm elsewhere. In comparison, only 74% and 65% could be achieved by the corrections based on daily and weekly bony matching on portal images, respectively.Conclusions: Results show that daily CT extent fitting provides a precise correction of prostate position in terms of CoG. Identifying prostate extents on five axial CT slices at the CT console is less time-consuming compared with daily contouring of the prostate on many slices. Taking advantage of the prostate curvature in the longitudinal direction, this method also eliminates the necessity of identifying prostate base and apex. Therefore, it is clinically feasible and should provide an accelerated localization of the prostate immediately before daily treatment. [Copyright &y& Elsevier]