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Stereotactic body radiotherapy is the preferred treatment modality for patients with inoperable early stage lung cancer. Chest wall toxicity is a potentially dose limiting side effect and may include fractures or pain secondary to treatment. The pathophysiology of these symptoms is unclear although it is presumed that radiation may alter the bone’s normal tissue environment, affecting maintenance and remodeling. Chest wall pain is likely neuropathic secondary to injury to the intercostal nerves. Identifying patients with chest wall toxicity can be difficult due to the varying definitions of toxicity as well as heterogeneous contouring guidelines. Multiple studies have demonstrated a correlation between treatment factors and the incidence of chest wall toxicity. An increase in dose and treatment volume appear to be the most consistent radiation factors associated with toxicity. Patient factors such as body mass index, female gender, tumor location, and age have also been correlated with an increased likelihood of developing side effects. Management of chest wall toxicity is typically conservative using analgesic medications although surgical intervention may be required for displaced fractures. In this review, we examine the treatment, patient, and tumor factors predictive for chest wall toxicity and the implications for the treating physician. [ABSTRACT FROM AUTHOR]

Background: Absolute lymphocyte count (ALC) is a laboratory value commonly obtained during workup of patients with Merkel cell carcinoma (MCC). Objective: We report the prognostic impact of ALC as a surrogate of immune status in MCC. Methods: A complete blood cell count was available for 64 patients with MCC in the month before definitive surgery, chemotherapy, or radiation. Statistical analysis was performed with classification and regression tree analysis, log rank test, and Cox model. Results: Median overall survival (OS) for the cohort was 97 months. Median OS for patients with an ALC less than 1.1 k/mm3 was 18.8 versus 110.1 months for those with ALC greater than or equal to 1.1 k/mm3 (P = .002, hazard ratio 0.29). Multivariate analysis of OS controlling for ALC, sex, stage, adjuvant chemotherapy, hematologic malignancy, and immunosuppression demonstrated ALC as a prognostic factor (P = .03). Disease-free survival at 36 months for ALC less than 1.1 k/mm3 was 26.9% versus 64.4% for those with ALC greater than or equal to 1.1 k/mm3 (P = .01). ALC was not a significant predictor for disease-free survival on multivariate analysis (P = .12). Limitations: This is a single-institution retrospective data set. Conclusion: ALC is associated with OS but not disease-free survival in MCC using a threshold of less than 1.1 k/mm3. This test may provide additional prognostic information for patients with MCC. [Copyright &y& Elsevier]

Purpose: To determine differences in clinical outcomes using intensity-modulated radiotherapy (IMRT) or a standard low neck field (LNF) to treat low neck. Methods and Materials: This is a retrospective, single-institution study. Ninety-one patients with squamous cell carcinoma of the head and neck were treated with curative intent. According to physician preference, some patients were treated with LNF (Planning Target Volume 3) field using a single anterior photon field matched to the IMRT field. Field junctions were not feathered. The endpoints were time to failure and use of a percutaneous endoscopic gastrostomy (PEG) tube (as a surrogate of laryngeal edema causing aspiration), and analysis was done with χ2 and log–rank tests. Results: Median follow-up was 21 months (range, 2–89 months). Median age was 60 years. Thirty-seven patients (41%) were treated with LNF, 84% were Stage III or IV. A PEG tube was required in 30%, as opposed to 33% without the use of LNF. Node 2 or 3 neck disease was treated more commonly without LNF (38% vs. 24%, p = 0.009). Failures occurred in 12 patients (13%). Only 1 patient treated with LNF failed regionally, 4.5 cm above the match line. The 3-year disease-free survival rate was 87% and 79% with LNF and without LNF, respectively (p = 0.2), and the 3-year LR failure rate was 4% and 21%, respectively (p = 0.04). Conclusions: Using LNF to treat the low neck did not increase the risk of regional failure “in early T and early N diseases” or decrease PEG tube requirements. [ABSTRACT FROM AUTHOR]

Purpose: To correlate tumor oxygenation status with long-term biochemical outcome after prostate brachytherapy. Methods and Materials: Custom-made Eppendorf Po 2 microelectrodes were used to obtain Po 2 measurements from the prostate (P), focused on positive biopsy locations, and normal muscle tissue (M), as a control. A total of 11,516 measurements were obtained in 57 men with localized prostate cancer immediately before prostate brachytherapy was given. The Eppendorf histograms provided the median Po 2, mean Po 2, and % <5 mm Hg or <10 mm Hg. Biochemical failure (BF) was defined using both the former American Society of Therapeutic Radiation Oncology (ASTRO) (three consecutive raises) and the current Phoenix (prostate-specific antigen nadir + 2 ng/mL) definitions. A Cox proportional hazards regression model evaluated the influence of hypoxia using the P/M mean Po 2 ratio on BF. Results: With a median follow-up time of 8 years, 12 men had ASTRO BF and 8 had Phoenix BF. On multivariate analysis, P/M Po 2 ratio <0.10 emerged as the only significant predictor of ASTRO BF (p = 0.043). Hormonal therapy (p = 0.015) and P/M Po 2 ratio <0.10 (p = 0.046) emerged as the only independent predictors of the Phoenix BF. Kaplan-Meier freedom from BF for P/M ratio <0.10 vs. ≥0.10 at 8 years for ASTRO BF was 46% vs. 78% (p = 0.03) and for the Phoenix BF was 66% vs. 83% (p = 0.02). Conclusions: Hypoxia in prostate cancer (low mean P/M Po 2 ratio) significantly predicts for poor long-term biochemical outcome, suggesting that novel hypoxic strategies should be investigated. [ABSTRACT FROM AUTHOR]

BACKGROUND: There is limited evidence that Merkel cell carcinoma (MCC) arising from a nodal basin without evidence of a primary cutaneous (PC) site has better prognosis. We present our experience at 2 tertiary care referral centers with stage III MCC with and without a PC site. METHODS: Fifty stage III MCC patients were identified between 1996 and 2011. Clinical data were analyzed, with primary endpoints being disease-free survival and overall survival. RESULTS: Of stage III patients, 34 patients presented with a PC site and 16 patients with an unknown primary (UP) site. Treatment strategies varied; of patients with UP vs PC sites, 25% vs 44% underwent combined regional lymphadenectomy and radiation, with an additional 25% vs 15% receiving chemotherapy. The median disease-free survival for a UP site was not reached vs 15 months for a PC site (hazards ratio = .48, P =.18). The median overall survival for a UP site was not reached vs 21 months for a PC site (hazards ratio = .34, P =.03). Multivariate analysis showed that UP status was a significant factor in overall survival (P = .002). CONCLUSIONS: Stage III MCC with a UP site portends a better prognosis than MCC with a PC site. [ABSTRACT FROM AUTHOR]