Search

Purpose Re-irradiation of recurrent glioblastoma (GBM) may delay further recurrence but re-irradiation increases the risk of radionecrosis (RN). Salvage therapy should focus on balancing local control (LC) and toxicity. We report the results of using intraoperative Cesium-131 (Cs-131) brachytherapy for recurrent GBM in a population of patients who also received bevacizumab. Methods and Materials Twenty patients with recurrent GBM underwent maximally safe neurosurgical resection with Cs-131 brachytherapy between 2010 and 2015. Eighty Gy was prescribed to 0.5 cm from the surface of the resection cavity. All patients previously received adjuvant radiotherapy and temozolomide, and received bevacizumab before or after salvage brachytherapy. Seven of 20 (35%) tumors were multiply recurrent and had been previously salvaged with external beam radiotherapy. Patients received MRI scans every 2 months monitored for recurrence, progression, and RN. Results Median tumor diameter was 4.65 cm (range, 1.2–6.3 cm). Median number of seeds pace was 41 (range, 20–74) with total seed activity 96.8U (range, 41.08–201.3U). At a median followup of 19 months, crude LC was 85% and median overall survival was 9 months (range, 5–26 months). There were two postoperative wound infections (10%), three seizures (15%), and 0% incidence of RN. Conclusions Our study demonstrates that while LC and survival are similar to other studies of postoperative external beam radiotherapy, no RN occurred in any of these patients, including 7 multiply re-irradiated patients. Of interest, there were patients with multiple recurrences whose survival extended beyond 20 months. These findings suggest that the use of highly conformal Cs-131 brachytherapy is a promising treatment for patients with recurrent GBM with minimal risk of development of RN.

Purpose To compare treatment plans and evaluate dosimetric characteristics of permanent cesium-131 (131Cs) vs. iodine-125 (125I) implants used in brain brachytherapy. Material and methods Twenty-four patients with 131Cs implants from a prospective phase I/II trial were re-planned with 125I implants. In order to evaluate the volume of brain tissue exposed to radiation therapy (RT), the dose volume histogram was generated for both radioisotopes. To evaluate the dosimetric differences of the two radioisotopes we compared homogeneity (HI) and conformity indices (CI), and dose covering 100% (D100), 90% (D90), 80% (D80), and 50% (D50) of the clinical target volume (CTV). Results At the 100%, 90%, 80%, and 50% isodose lines, the 131Cs plans exposed less mean volume of brain tissue than the 125I plans (p < 0.001). The D100, D90, D80, and D50 were smaller for 131Cs (p < 0.001). The HI and CI for 131Cs vs. 125I were 19.71 vs. 29.04 and 1.31 vs. 1.92, respectively (p < 0.001). Conclusions Compared to 125I, 131Cs exposed smaller volumes of brain tissue to equivalent doses of radiation and delivered lower radiation doses to equivalent volumes of the CTV. 131Cs exhibited a higher HI, indicating increased uniformity of doses within the CTV. Lastly, 131Cs presented a CI closer to 1, indicating that the total volume receiving the prescription dose was closer to the desired CTV volume. These results suggest that 131Cs is dosimetrically superior to 125I and may explain the reason for the 0% incidence of radiation necrosis (RN) in our previously published prospective study using 131Cs.

Mindfulness, defined as awareness of the moment while acknowledging and accepting one's feelings, thoughts, and sensations, is the aim of mindfulness meditation. Our objective was to investigate the relationship between burnout, mindfulness, fulfillment, and other personal characteristics in radiation oncology (RO) residents/attendings compared with other specialties.From December 2019 to February 2020, residents and attendings in multiple specialties at a single tertiary care academic institution were sent surveys, including the mindfulness attention awareness scale, Stanford professional fulfillment index, and a personal questionnaire. A Pearson correlation was conducted on the relationship between mindfulness, fulfillment, disengagement, and exhaustion. To determine risk factors for burnout (overall burnout ≥ 1.33), a univariate analysis was conducted to yield odds ratios (ORs) on debt, specialty, income, sleep, exercise, marital status, number of children, work hours, mindfulness (mindfulness attention awareness scale ≥ 4), fulfillment (professional fulfillment ≥ 3), and time with family/friends. Significant factors on univariate analysis were entered into multivariate analysis.There were 180 surveys completed by 60 residents and attendings across 17 specialties. Eighteen (30%) respondents were in RO. Mindfulness positively correlated with fulfillment (RO physicians experienced less burnout than physicians in other specialties at our institution. Mindfulness, professional fulfillment, moderate work hours, and spending time with loved ones protected against burnout. Further study of interventions to promote mindfulness and fulfillment may help us understand how best to improve the mental and emotional health of RO physicians.

Brain metastases are the most common intracranial malignancies in adults. Surgical resection is the preferred treatment approach when a pathological diagnosis is required, for symptomatic patients who are refractory to steroids, and to decompress lesions causing mass effect. Radiotherapy is administered to improve local control rates after surgical resection. After a brief review of the literature describing the treatment of brain metastases using whole-brain radiotherapy, postoperative stereotactic radiosurgery, preoperative radiosurgery, and brachytherapy, we compare patient-related, technical, practical, and radiobiological considerations of each technique. Finally, we focus our discussion on intraoperative brachytherapy, with an emphasis on the technical aspects, benefits, efficacy, and outcomes of studies utilizing permanent Cs-131 implants.

Purpose/Objective(s): The COVID-19 pandemic has had considerable impact on volume of outpatient procedures, including radiation therapy, a critical treatment option for cancer patients. In order to measure the impact, we performed a retrospective review of patients treated at our multicenter institution with curative or palliative radiation over the past three years. Materials/Methods: Patients treated with radiation (n = 7,935) at our institution between 1/1/2018 and 12/31/2020 were retroactively enrolled in this IRB exempt study. Data elements such as primary cancer site, age, sex, and treatment intent were captured through our oncology analytics platform. Pearson's Chi square test for significance was used to assess a null hypothesis that there was no significant difference in treatment volume or treatment intent by disease system between 2018-2019 and 2020. Results: Median patient age in 2018-2019 was 67.3 (IQR: 59-75) vs. 67.55 (59-75) in 2020. The total number of patients starting treatment per year declined between 2018-2019 and 2020 from 1774.5 to 1606 (curative intent) and 1001 to 778 (palliative intent). Patient counts by disease system and treatment intent are summarized in the table. There were significant differences in the distribution of disease systems over time (X2 = 30.386, df = 10, P

PURPOSE/OBJECTIVE(S) Mindfulness, defined as awareness of the present moment is a type of meditation practice. We evaluated whether mindfulness or social support affects stress burden in patients undergoing radiation therapy (RT) for cancer. In addition, we wanted to evaluate whether mindfulness and perceived stress impacts opioid use in patients undergoing radiation therapy for Head and Neck (HN) cancers. MATERIALS/METHODS From July 2019 to January 2021, patients receiving RT for cancer were given 3 surveys to complete prior to starting treatment. The surveys included the Mindfulness Attention Awareness Scale (MAAS), Medical Outcomes Study Social Support Survey (MOS), and the Perceived Stress Scale (PSS) which were used to measure mindfulness, social support, and stress respectively. A Pearson correlation was conducted for this initial analysis. In addition, MAAS and PSS scales were assessed in 20 patients (40 surveys) with HN cancer to evaluate opioid use. The Spearman correlation coefficient was used to test for associations between PSS, MAAS, age and elapsed days. The Mann-Whitney test was used to compare the distributions of PSS and MAAS between males and females, and between the opioid users and non-users. RESULTS In the initial analysis of 93 patients and 279 surveys, treatment sites included prostate, breast, HN, GI, CNS, lung, gynecologic, bone, and palliative pelvis, median scores for PSS, MAAS, and MOS were 14.0 (range:0-28, standard deviation:6.2), 5.1 (range: 2.8-6.0, standard deviation:0.8), and 4.6 (range: 0-5, standard deviation:1.0) respectively. Stress scores were in the low, average, and high stress ranges for 35 (38%), 26 (28%), and 32 (34%) patients respectively. Stress was negatively correlated to mindfulness, r = -0.494, P < 0.001. Social support was positively correlated to mindfulness, r = 0.264, P < 0.001, and negatively correlated to stress r = -0.340, P < 0.001. We added additional 10 patients in HN cohort (n = 20) where we compared MAAS/PSS with opioid use and we did not find a significant correlation between PSS and MASS (r = -.30, P = .20), MASS and age (r = .40, P = .08), or MASS and elapsed days (r = -.28, P = .22). The median PSS in the opioid group and non-opioid groups were 2.1 (1.7-2.3) (P = 0.32) and 1.9 (1.1-2.1) (P = 0.27), respectively. CONCLUSION Mindfulness did correlate with less stress and more social support. There was no correlation found between MAAS and opioid use. We plan to continue the study in a larger cohort of patients.

Low-dose-rate (LDR) brachytherapy and stereotactic body radiation therapy (SBRT) have both shown acceptable outcomes in the treatment of low- and intermediate-risk prostate cancer. Minimal data have been published directly comparing rates of biochemical control and toxicity with these 2 modalities. We hypothesize that LDR and SBRT will provide similar rates of biochemical control.All low- and intermediate-risk patients with prostate cancer treated definitively with SBRT or LDR between 2010 and 2018 were captured. Phoenix definition was used for biochemical failure. Independent t tests were used to compare baseline characteristics, and repeated measure analysis of variance test was used to compare American Urologic Association (AUA) and the Expanded Prostate Cancer Index Composite (EPIC) scores between treatment arms over time. Biochemical control was estimated using the Kaplan-Meier method. Differences in acute and late toxicity were assessed via Pearson χIn the study, 219 and 118 patients were treated with LDR and SBRT. Median follow-up was 4.3 years (interquartile range, 3.1-6.1). All patients treated with LDR received 125.0 Gy in a single fraction. SBRT consisted of 42.5 Gy in 5 fractions. Five-year biochemical control for LDR versus SBRT was 91.6% versus 97.6% (P = .108). LDR patients had a larger increase in mean AUA scores at 1 month (17.2 vs 10.3, P.001) and 3 months posttreatment (14.0 vs 9.7, P.001), and in mean EPIC scores at 1 month (15.7 vs 13.8, P.001). There was no significant difference between LDR and SBRT in late grade 3 genitourinary toxicity (0.9% vs 2.5%, P = .238); however, LDR had lower rates of late grade 3 gastrointestinal toxicity (0.0% vs 2.5%, P = .018).Our data show similar biochemical control and genitourinary toxicity rates at 5 years for both SBRT and LDR, with slightly higher gastrointestinal toxicity with SBRT and higher AUA and EPIC scores with LDR.

PURPOSE/OBJECTIVE(S) There is limited data on the use of SBRT for salvage or consolidative treatment of Head and Neck cancers. Given the relatively poor prognosis for recurrent HN cancers and risk of toxicity with the addition of hypofractionated RT after conventional IMRT, we wanted to evaluate patients that should receive SBRT. MATERIALS/METHODS Patients with HN cancer treated in Radiation Medicine were selected and data collected using a data extraction software. This data extraction software collects data from electronic medical records at a large tertiary care academic medical center. Consecutively treated patients with adequate documentation were selected. Data gathered included primary sites of cancer, the initial total dose from conventional treatment, number of fractions, SBRT total dose and fractions, metastatic disease or locoregional progression, types of grade 3-5 toxicity (CTCAE v four toxicity), time to develop toxicity and progression and time since SBRT to last follow-up. Time to toxicity was estimated using the Kaplan-Meier product limit method, and each factor was compared using the log-rank test. RESULTS Median age was 69 (Range 39-90). The median time between EBRT/ChemoRT and SBRT was six months (1-108 months). There were 59 males (71%) and 24 females (29%). The primary HN sites included oropharynx (OP) (37%), oral cavity (OC) (24%), hypopharynx, neck, salivary gland, paranasal sinus, and larynx cancers. The most common histology was squamous cell cancers, although less common histologies include salivary duct adenocarcinoma and esthesioneuroblastoma among others. Ten patients (12%) received SBRT after surgical resection of recurrence. Thirty-four patients (41%) were censored alive at / = 12 months developed grade 3 or 4 toxicity while 16 of 47 (34%) developed grade 3/4 toxicity with follow-up 5, P = 0.0114), post-op SBRT (P = 0.0018) and the interval between EBRT/CRT and SBRT (P = 0.02). There was field overlap between EBRT and SBRT in all patients. Adverse outcomes include necrosis, fistula, stomal bleeding, seizure, intractable pain, and PEG dependence. CONCLUSION SBRT after full dose EBRT should be used in select patients given its toxicity and limited survival in patients with advanced/locally recurrent head and neck cancer. We are planning a prospective evaluation of the use of SBRT in recurrent/locally advanced settings.

Limited work, either retrospective or prospective, has been done to investigate whether or not there is a cause-specific mortality (CSM) or all-cause mortality (ACM) benefit to adding surgery following neoadjuvant treatment for Stage IIIB NSCLC. We extracted patients with Stage IIIB NSCLC from the Survival, Epidemiology, and End Results Program (SEER) database treated from 2004 to 2012 with either radiation alone or radiation followed by surgery. Other variables extracted were age, sex, race, and tumor location. The impact of patient and treatment variables on CSM and ACM was explored using Cox multivariable regression analysis. A total of 14,065 patients were extracted from the SEER database. On multivariable analysis, even after adjustment for age, gender, race, and site, radiation followed by surgery was associated with a reduction in cause-specific mortality compared to radiation alone (adjusted HR 0.46; 95 % CI 0.41, 0.52; p

Purpose Seed migration after interstitial prostate brachytherapy has been well documented in the literature. However, there have been no detailed reports of seed migration after permanent interstitial brachytherapy to treat cerebral malignancies. In this article, the authors report a rare case of seed migration after adjuvant cesium-131 ( 131 Cs) brachytherapy was used to treat a large paraventricular brain metastasis. Methods and materials The patient was a 63-year-old man with a 5.8-cm right frontal metastasis abutting the right lateral ventricle and causing severe edema and mass effect. The patient was enrolled in an ongoing clinical trial at our institution to receive permanent intraoperative 131 Cs brachytherapy in an effort to prevent tumor recurrence in the resection cavity. Stranded seeds were covered with Surgicel, and the cavity was filled with Tisseel to prevent seed migration. Results Imaging obtained at 54 days postsurgery showed no seed migration, but imaging obtained at 158 days revealed 12 brachytherapy seeds in the spinal canal from T11 to S2. The seeds were left in place because they were inactive at this time due to the short half-life of 131 Cs (9.7 days); they remained stable on followup imaging, and the patient was asymptomatic. Conclusions Although the clinical consequences remain unclear, the migration of inactive seeds is not currently considered to be a complication of intracerebral brachytherapy and we do not believe that additional measures must be taken to prevent it.

Purpose: While brachytherapy is often used concurrently with flap reconstruction following surgical ablation for head and neck cancer, it remains unclear whether it increases morbidity in the particularly high risk subset of patients undergoing salvage treatment for recurrent head and neck cancer (RH&NC). Material and methods : A retrospective chart review was undertaken that evaluated patients with RH&NC who underwent flap coverage after surgical re-resection and concomitant brachytherapy. The primary endpoint was flap viability, and the secondary endpoints were flap and recipient site complications. Results : In the 23 subjects included in series, flap viability and skin graft take was 100%. Overall recipient site complication rate was 34.8%, high-dose radiation (HDR) group 50%, and low-dose radiation (LDR) group 29.4%. There was no statistically significant difference between these groups. Conclusions : In patients who undergo flap reconstruction and immediate postoperative radiotherapy following salvage procedures for RH&NC, flap coverage of defects in combination with brachytherapy remains a safe and effective means of providing stable soft tissue coverage.

Purpose Non-melanomatous skin cancer (NMSC) is the single most common cancer in the US. Radiation therapy is an excellent treatment alternative to surgery. High-dose-rate (HDR) brachytherapy and external beam radiotherapy (EBRT) are commonly used radiation treatment modalities but little data is published comparing these modalities. We present our institution's experience and outcomes with these therapeutic options. Material and methods From June 2005 to March 2013, 61 patients were treated with HDR brachytherapy (n = 9), hypofractionated EBRT (n = 30), or standard fractionation EBRT (n = 22) for NMSC. The primary outcome measure was local control at most remote follow-up and secondary outcome measures were overall survival, cosmetic outcome, and toxicity. Univariate analysis was performed to compare outcomes between treatment modalities. Kaplan-Meier analysis and log-rank test were used to compare overall survival. Results Median follow-up was 30 months. The most common histologies were BCC (47%) and SCC (44%); mean patient age was 83.3 years. Local control was 81% and 2-year actuarial overall survival was 89%. There was no statistical difference in local control or overall survival between treatment modalities. There was no statistical difference in cosmetic outcome or toxicity between treatment modalities, although five of six “poor” cosmetic outcomes and the only grade 3 toxic events were found in the standard fractionation EBRT group. Conclusions All modalities investigated represent effective treatments for NMSC and have good cosmetic outcomes and acceptable toxicity profiles. The finding of higher grade toxicity and a greater portion of patients experiencing toxicity among standard fractionation therapy is counter to expectations. There was no statistical significance to the finding and it is not likely to be meaningful.

Purpose Radiation oncology curriculum development is challenging because of limited numbers of trainees at any single institution. The goal of this project is to implement and evaluate a standardized medical student clerkship curriculum following the multi-institutional cooperative group research model. Methods During the 2013 academic year, a standardized curriculum was implemented at 11 academic medical centers consisting of three 1-hour lectures and a hands-on radiation treatment planning workshop. After the curriculum, students completed anonymous evaluations using Likert-type scales (1 = "not at all" to 5 = "extremely") and free responses. Evaluations asked students to rate their comfort, before and after the curriculum, with radiation oncology as a specialty, knowledge of radiotherapy planning methods, and ability to function as a radiation oncology resident. Nonparametric statistical tests were used in the analysis. Results Eighty-eight students at 11 academic medical centers completed the curriculum de novo, with a 72.7% (64 of 88) survey response rate. Fifty-seven students (89.1%) reported intent to pursue radiation oncology as their specialty. Median (interquartile range) student ratings of the importance of curricular content were as follows: overview, 4 (4-5); radiation biology/physics, 5 (4-5); practical aspects/emergencies, 5 (4-5); and planning workshop, 4 (4-5). Students reported that the curriculum helped them better understand radiation oncology as a specialty (5 [4-5]), increased specialty decision comfort (4 [3-5]), and would help the transition to radiation oncology residency (4 [4-5]). Students rated their specialty decision comfort significantly higher after completing the curriculum (4 [4-5] versus 5 [5-5]; P Conclusions A national standardized curriculum was successfully implemented at 11 academic medical centers, providing proof of principle that curriculum development can follow the multi-institutional cooperative group research model.

Purpose To update brachytherapy recommendations for pretreatment evaluation, treatment, and dosimetric issues for thoracic brachytherapy for lung cancer. Methods and Materials Members of the American Brachytherapy Society with expertise in thoracic brachytherapy updated recommendations for thoracic brachytherapy based on literature review and clinical experience. Results The American Brachytherapy Society consensus guidelines recommend the use of endobronchial brachytherapy for disease palliation in patients with central obstructing lesions, particularly in patients who have previously received external beam radiotherapy. The use of interstitial implants after incomplete resection may improve outcomes and provide enhanced palliation. Early reports support the use of CT-guided intratumoral volume implants within clinical studies. The use of brachytherapy routinely after sublobar resection is not generally recommended, unless within the confines of a clinical trial or a registry. Conclusions American Brachytherapy Society recommendations for thoracic brachytherapy are provided. Practitioners are encouraged to follow these guidelines and to develop further clinical trials to examine this treatment modality to increase the evidence base for its use.

Purpose: The feasibility and efficacy of re-irradiation using contemporary radiation techniques to treat recurrent head and neck cancer has been demonstrated but the role of brachytherapy is unclear. Here we describe the use of 131 Cs brachytherapy with concurrent salvage surgery in 18 patients. Material and methods: Eligible patients underwent maximal gross resection of the tumor with implantation of brachytherapy seeds delivering a minimum dose of 80 Gy to the tumor bed. Rates of overall survival, locoregional progression free survival, disease-free survival, and radiation-induced toxicity were analyzed. Results: Retrospective Kaplan-Meier analysis shows median overall survival was 15 months and disease free survival was 12 months. Two patients developed grade 3 toxicity; all other complications were grade 1-2 with no grade 4 or 5 complications. Conclusions: Compared to prior literature, our study shows comparable rates of survival with a decreased rate of radiation-induced toxicity. J Contemp Brachytherapy 2015; 7, 6: 445-452 DOI: 10.5114/jcb.2015.56764

Purpose The purpose of the study was to evaluate the outcomes for wedge resection (WR), WR plus brachytherapy (WRB), or stereotactic body radiation therapy (SBRT) for early stage non-small lung cancer. Methods and Materials Retrospectively collected data of patients treated with WR, WRB, or SBRT (1993–2012). Cesium-131 (Cs131) used in WRB group in patients with close or positive margins based on surgical assessment. Kaplan–Meier survival analysis, log-rank test used to compare disease-free survival/overall survival between different groups. Multivariable analysis, using Cox proportional hazards regression analysis, was performed to evaluate the independent effect of age, gender, and treatment procedure on disease-free survival. Results A total of 272 patients were included in the study (123 WR, 52 WR+Cs-131, 97 SBRT). Cs-131 was used with WRs that the surgeons deemed high risk. Local control (LC) was similar in the three groups and was achieved in 92.2% for WR group vs. 96.2% for WR+Cs-131 and 95.5% for SBRT (p = 0.60). On multivariate analysis, although females showed a higher LC, neither LC nor distant metastasis were associated with age or gender (p = 0.65 and p = 0.41, respectively). Five-year overall survival was 100% in the WR+B group, 97.7% in the WR group, and 89.6% in the SBRT group (p = 0.02). Toxicity was similar in the three groups. Conclusion WR, WR+ Cs-131, or SBRT are all excellent treatment options for patients with early stage non-small cell lung cancer that are not candidates for lobectomy. For high risk WRs, we favor use of Cesim-131 brachytherapy. Until a prospective randomized comparative study is done to evaluate the best treatment approach for early stage NSCLC, treatment selection should be based on a multidisciplinary team approach.

Objective: The objective of this study was to compare robotic-prostatectomy plus adjuvant radiation therapy (RPRAT) versus primary RT for high-risk prostate cancer (HRPCa). Materials and Methods: A retrospective chart review was performed for the HRPCa patients treated in our institution between 2000 and 2010. One hundred and twenty-three patients with high-risk disease were identified. The Chi-square test and Fisher's exact test were used to compare local control and distant failure rates between the two treatment modalities. For prostate-specific antigen comparisons between groups, Wilcoxon rank-sum test was used. Results: The median follow-up was 49 months (range: 3-138 months). Local control, biochemical recurrence rate, distant metastasis, toxicity, and disease-free survival were similar in the two groups. Conclusions: Primary RT is an excellent treatment option in patients with HRPCa, is equally effective and less expensive treatment compared with RPRAT. A prospective randomized study is required to guide treatment for patients with HRPCa.

Cesium-131 (Cs) brachytherapy is a safe and convenient treatment option for patients with resected brain tumors. This study prospectively analyzes radiation exposure in the patient population who were treated with a maximally safe neurosurgical resection and Cs brachytherapy. Following implantation, radiation dose rate measurements were taken at the surface, 35 cm, and 100 cm distances. Using the half-life of Cs (9.69 d), the dose rates were extrapolated at these distances over a period of time (t = 30 d). Data from dosimetry badges and rings worn by surgeons and radiation oncologists were collected and analyzed. Postoperatively, median dose rate was 0.2475 mSv h, 0.01 mSv h, and 0.001 mSv h and at 30 d post-implant, 0.0298 mSv h, 0.0012 mSv h, and 0.0001 mSv h at the surface, 35 cm, and 100 cm, respectively. All but one badge and ring measured a dose equivalent corresponding to ~0 mSv h, while 1 badge measured 0.02/0.02/0.02 mSv h. There was a significant correlation between the number of seeds implanted and dose rate at the surface (p = 0.0169). When stratified by the number of seeds: 4-15 seeds (n = 14) and 20-50 seeds (n = 4) had median dose rates of 0.1475 mSv h and 0.5565 mSv h, respectively (p = 0.0015). Using National Council on Radiation Protection guidelines, this study shows that dose equivalent from permanent Cs brachytherapy for the treatment of brain tumors is limited, and it maintains safe levels of exposure to family and medical personnel. Such information is critical knowledge for the neurosurgeons, radiation oncologists, nurses, hospital staff, and family as this method is gaining nationwide popularity.

Purpose: Poorly differentiated thyroid carcinoma (PDTC) and anaplastic thyroid carcinoma (ATC) are considered the most aggressive cancers of the head and neck. The aim of the study was to evaluate and compare survival outcomes in PDTC and ATC in a large population-based cohort. Materials and Methods: Patients with PDTC and ATC diagnosed from 1973 to 2008 were obtained from Surveillance, Epidemiology, and End Results database. Kaplan-Meier survival analysis and log-rank analyses were performed to evaluate (1) The effect of histology on cause-specific survival (CSS) and (2) the influence of factors such as treatment, treatment sequence, race, sex, and age on CSS. Multivariate analysis was performed to assess the independent effect of these factors on CSS. Results: A total of 1352 patients with PDTC and ATC were identified. PDTC constituted 52.4% of patients versus 47.6% for ATC. Median CSS was similar in the two histology groups (P = 0.14). Both PDTC and ATC patients receiving radioisotopes showed a significantly better CSS compared to external beam radiation (P < 0.0001). PDTC and ATC Patients receiving radiation prior to surgery demonstrated a significantly lower CSS compared to patients receiving radiation postoperatively (P < 0.0001). Female gender and black/nonwhite race tended to improve CSS in PDTC and ATC patients (P = 0.29 and P = 0.03, for gender and race, respectively). However, multivariate analysis revealed only type of radiation treatment and age to be independently associated with CSS. Conclusion: This is the first large population-based study evaluating PDTC and ATC outcomes in patients who received radiation treatment. Radioisotope use and timing of radiotherapy (postoperative vs. preoperative) were associated with improved CSS in both histologies.

To examine a relationship between serum transforming growth factor β -1 (TGF-β1) values and radiation-induced fibrosis (RIF).We conducted a prospective analysis of the development of RIF in 39 women with American Joint Committee on Cancer stage 0-I breast cancer treated with lumpectomy and accelerated partial breast irradiation via intracavitary brachytherapy (IBAPBI). An enzyme-linked immunoassay (Quantikine, RD, Minneapolis, MN) was used to measure serum TGF-β1 before surgery, before IBAPBI, and during IBAPBI. Blood samples for TGF-β1 were also collected from 15 healthy, nontreated women (controls). The previously validated tissue compliance meter (TCM) was used to objectively assess RIF.The median time to follow-up for 39 patients was 44 months (range, 5-59 months). RIF was graded by the TCM scale as 0, 1, 2, and 3 in 5 of 20 patients (25%), 6 of 20 patients (30%), 5 of 20 patients (25%), and 4 of 20 patients (20%), respectively. The mean serum TGF-β1 values were significantly higher in patients before surgery than in disease-free controls, as follows: all cancer patients (30,201 ± 5889 pg/mL, P=.02); patients with any type of RIF (32,273 ± 5016 pg/mL, P.0001); and women with moderate to severe RIF (34,462 ± 4713 pg/mL, P0.0001). Patients with moderate to severe RIF had significantly elevated TGF-β1 levels when compared with those with none to mild RIF before surgery (P=.0014) during IBAPBI (P≤0001), and the elevation persisted at 6 months (P≤.001), 12 months (P≤.001), 18 months (P≤.001), and 24 months (P=.12). A receiver operating characteristic (ROC) curve of TGF-β1 values predicting moderate to severe RIF was generated with an area under the curve (AUC)ROC of 0.867 (95% confidence interval 0.700-1.000). The TGF-β1 threshold cutoff was determined to be 31,000 pg/mL, with associated sensitivity and specificity of 77.8% and 90.0%, respectively.TGF-β1 levels correlate with the development of moderate to severe RIF. The pre-IBAPBI mean TGF-β1 levels can serve as an early biomarker for the development of moderate to severe RIF after IBAPBI.

Purpose Soft-tissue sarcomas most frequently metastasize to the lung. Surgical resection of pulmonary metastases is the primary treatment modality. Although lobectomy is widely acknowledged as the standard procedure to treat primary pulmonary tumors, the standard for pulmonary metastases is not well defined; furthermore, compromised lung function may tip the scales in favor of a less invasive approach. Here, we report the results of a patient treated with wedge resection and intraoperative cesium-131 ( 131 Cs). Methods and Materials A 58-year-old African American female was diagnosed with the American Joint Committee on Cancer Stage IIA mixed uterine leiomyosarcoma and underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by adjuvant external beam radiotherapy to a total dose of 45 Gy and vaginal brachytherapy to a total dose of 20 Gy. At 2 years, a routine CT scan of the chest revealed metastasis to right upper lobe of the lung. The patient's poor pulmonary function, related to a 45 pack-year smoking history and chronic emphysema, precluded a lobectomy. Results After the patient underwent a lung-sparing wedge resection of the pulmonary right upper lobe metastasis and intraoperative brachytherapy with 131 Cs seeds to a total dose of 80 Gy, she remained disease free in the implanted area. At a 2-year followup, imaging continued to reveal 100% local control of the area treated with wedge resection and intraoperative 131 Cs brachytherapy. The patient had no complications from this treatment. Conclusions Such treatment approach may become an attractive option in patients with oligometastatic disease and compromised pulmonary function.

The purpose of this study was to compare the rates of urinary tract infection (UTI) among patients with endometrial cancer receiving vaginal brachytherapy alone and brachytherapy plus 3-dimensional conformal radiation therapy (3DCRT) or intensity modulated radiation therapy (IMRT).We retrospectively evaluated the rates of UTI among 581 patients diagnosed with endometrial cancer, treated between 2004 and 2012. A total of 37% (216/581) received brachytherapy alone, 28% (161/581) received brachytherapy plus 3DCRT, and 35% (204/581) received brachytherapy plus IMRT. UTI during the treatment was defined as evidence of pyuria detected by either urine dipstick or urinalysis. All specimens were collected as a clean catch, midstream void to avoid contamination and resultant false positives. The χ(2) and logistic regression analyses were subsequently employed for statistical analyses.UTI was diagnosed in 14.6% (85/581) of all patients. Only 2.8% (6/216) of patients receiving brachytherapy were diagnosed with a UTI during treatment, whereas UTI was diagnosed in 37.3% (60/161) of patients receiving brachytherapy plus 3DCRT, and 9.3% (19/204) of patients receiving brachytherapy plus IMRT (P.0005). Logistic regression analysis found a decreased association between UTI and stage III endometrial cancer (odds ratio [OR], 0.51, 95% confidence interval [CI], 0.26, 0.99; P = .048). When compared with brachytherapy, both types of external beam radiation therapy were associated with an increased risk of UTI, though adjuvant 3DCRT (OR, 47.52, 95% CI, 14.81, 152.47; P.001) had a more dramatic risk increase than IMRT (7.89, 95% CI, 2.26, 27.62; P = .001).When compared with IMRT, 3DCRT is associated with a significantly increased risk of UTI, supporting the use of IMRT as the less toxic external beam radiation therapy for endometrial cancer.

Radiation therapy for early stage lung cancer is a promising modality. It has been traditionally used in patients not considered candidates for standard surgical resection. However, its role has been changing rapidly since the introduction of new and advanced technology, especially in tumor tracking, image guidance, and radiation delivery. Stereotactic radiation therapy is one such advancement that has shown excellent local control rates and promising survival in early stage lung cancer. In addition, the toxicity profiles are quite favorable. In addition to stereotactic radiation, advances in brachytherapy techniques have enabled high local control rates in operable patients who receive sublobar resections due to compromised pulmonary function. Isotopes that have been used include iodine-125, palladium-103, and cesium-131. In this review article, the role of radiation therapy in treatment of lung cancer, patient selection, outcomes, toxicity and recent technological advancements are discussed. The radiation therapy techniques described in this article are also being used in the management of locally advanced lung cancers.

Medical students applying for radiation oncology residency rated “perceived quality of didactics” within the top 5 factors in ranking programs (1). However, according to a 2013 national survey, only 27% of radiation oncology clerkships included didactic components specifically for medical students (2). In 2012, a pilot radiation oncology clerkship curriculum was developed at two institutions using the six-step conceptual framework for medical education curriculum development by Kern et al (3). Eighteen students completed the pilot curriculum. Students rated the curriculum highly and reported improved comfort with their decision to pursue radiation oncology as a specialty (4). Using the cooperative group research model, the curriculum was expanded to 11 selected academic medical centers within the United States in 2013 with the goal of increasing the number of participating students to provide more robust feedback for further curriculum development. Here, we describe the structure of the curriculum with corollary student feedback that can be used by other institutions to design or enhance their medical student curriculum. The curriculum consisted of three 1-hour lectures delivered by a senior resident or faculty member; topics included: (1) an overview of radiation oncology, including a history of the specialty, types of treatments, and basic clinic flow; (2) fundamentals of radiation biology and radiation physics; and (3) practical aspects of radiation treatment simulation and planning and radiation emergencies. Ideally, one session was conducted per week with all students present. The lecture format was open, and students were encouraged to ask questions. In addition, a 1-hour hands-on radiation treatment workshop facilitated by a senior resident, faculty, physicist, or dosimetrist was implemented to teach students the fundamentals of radiation treatment planning (5). While using a radiation treatment planning workstation, each student was provided with a step-by-step guide to delineating a radiation target, selecting appropriately directed radiation beams, and modifying various beam parameters to achieve an optimal plan. Individual institutions were encouraged to adapt the lectures according to institutional treatment or practice patterns, but all institutions retained the core curriculum format (3 lectures, 1 planning session). All participating institutions obtained institutional review board exemption. A total of 94 students participated in the curriculum in the 2013 academic year, allowing both wide dissemination and robust feedback. Upon completion of the clerkship, students were invited to complete an anonymous internet-based survey to rate the curriculum components, which yielded a 73% response rate. Qualitative analysis of the evaluations was undertaken by two authors (P.M. and J.C.Y.). Evaluation-free responses were reviewed independently and divided into positive and negative “consistent” themes (Table 1). These themes reflected the students' subjective overall feeling that the course laid an excellent knowledge foundation for transition to residency and their concern that they might not retain the knowledge during the two years prior to beginning residency. Future directions for curriculum development include expansion to additional institutions while using these constructive comments to enhance the learning experience. For example, one negative theme was that lectures should be scheduled earlier in the rotation to ensure that students have a good knowledge base for the remainder of the clinical rotation. This and other constructive feedback will be considered in the future when implementing the curriculum. Table 1 Consistent positive and negative feedback themes for individual curriculum components and how the curriculum will or will not be useful for transition to residency and for the overall curriculum This successful implementation of a standardized curriculum piloted at multiple institutions provides proof-of-principle that curriculum development can follow the multi-institutional cooperative group model. In the process, we identified areas of positive and negative needs as perceived by the students, who represent the most important stakeholders. Additional data are being collected to assess the impact of this curriculum on the students' decision to apply for radiation oncology residency. In the interim, the current data can help individual departments enhance their ongoing curriculum for rotating medical students.

Renal cell carcinoma (RCC) is an aggressive malignancy that carries a poor prognosis, especially in patients presenting with advanced stage. Primary treatment for localized RCC is surgical resection however, a significant number of patients still develop locoregional and distant metastasis after curative resection. In metastatic disease, radiation therapy (RT) has been used for palliation routinely for brain and other extracranial lesions with respectable response rates. However, RT for primary RCC has questionable benefit. In this article, the authors discuss the evidence with regards to the role of RT in primary RCC either as a primary treatment, adjuvant treatment, or preoperatively to improve resection outcomes. In addition, novel RT techniques such as stereotactic body radiation therapy and its use in RCC management are also addressed. Finally, the authors discuss the techniques and doses of RT for primary RCC.

Retiform hemangioendothelioma (RH) is an infrequently encountered vascular neoplasm of intermediate or borderline malignancy. Treatment of RH is controversial. We present a case of a 44-year-old Asian male presenting with an unresectable RH of the pelvis. The patient was treated with concurrent low-dose Cisplatin and External beam Radiation (4140cGy in 180cGy per fraction). This is the first report of a clinical complete response and a long-term local control of this rare tumor. This has significant clinical implication, since it gives the first evidence of treatment of this rare tumor using concurrent low-dose chemotherapy and radiation.