Search

Background: Patient-generated health data (PGHD), which includes patient-reported outcomes (PROs) and wearable device data, may have prognostic value for cancer patients. We tested that hypothesis using data from several prospective trials where patients with locally advanced non-small cell lung cancer (LA-NSCLC) were treated with definitive chemoradiotherapy., Methods: Cox proportional hazards models were utilized to identify the baseline patient-reported symptom that best predicted progression-free survival (PFS) duration in a trial that involved PRO-CTCAE collection (Cohort 1). Using data from trials that included EORTC QLQ-C30 questionnaires and wearable devices (Cohort 2), the same symptom was tested as a predictor of PFS. Baseline physical inactivity was also tested as a predictor of PFS. A simple risk stratification tool utilizing PROs and physical activity was proposed., Results: In Cohort 1 (n = 50), anorexia was the only pretreatment PRO that was significantly associated with PFS after Bonferroni correction (HR = 3.94, P = .002). In Cohort 2 (n = 58), baseline anorexia was also significantly associated with PFS (HR = 2.48, P = .018), as was physical inactivity (HR = 3.11, P < .001). Median PFS duration for patients in Cohort 2 with anorexia or physical inactivity was 6 months, compared to 18 months for other patients (HR = 3.08, P < .001). Median overall survival duration for patients with anorexia or physical inactivity was 19 months, compared to 65 months for other patients (HR = 2.44, P = .021)., Conclusion: PGHD, including PROs and wearable device data, can provide valuable prognostic information for LA-NSCLC patients treated with definitive chemoradiotherapy. These findings should be validated using larger datasets., Competing Interests: Disclosure The authors have no disclosures that are directly related to this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: For most locally advanced non-small cell lung cancer (LA-NSCLC) patients who complete definitive chemoradiotherapy (CRT) and do not experience disease progression, one year of adjuvant durvalumab is recommended. Here, we explore causes and consequences of early durvalumab discontinuation., Materials and Methods: We reviewed patients treated for LA-NSCLC with definitive CRT who began adjuvant durvalumab between 2017 and 2021. Duration of durvalumab receipt and causes for early discontinuation were tabulated. Logistic regression models were utilized to evaluate predictors of early durvalumab discontinuation. Landmark analyses were performed to explore associations between early durvalumab discontinuation and clinical outcomes (progression-free survival (PFS), overall survival (OS))., Results: Fifty-nine patients were included. Forty-one patients (69%) discontinued durvalumab early, most commonly for disease progression (n = 14) or lung toxicity (n = 10). Multivariable analysis revealed mean heart radiotherapy dose (MHD) was associated with risk of durvalumab discontinuation from progression (HR = 2.34 per 10 Gy, p = 0.052), and there was a trend suggesting an association between MHD and risk of durvalumab discontinuation from lung toxicity (HR = 2.16 per 10 Gy, p = 0.126). Median PFS duration following durvalumab initiation was 14 months, and median OS duration was 32 months. Landmark analyses that excluded patients with progression or death within one year of durvalumab initiation demonstrated improved outcomes for patients who completed one year of durvalumab (2-year PFS 100% v. 40%, p < 0.001; 2-year OS 100% v. 67%, p = 0.862). Improved outcomes were observed for patients who received MHD below the cohort median (9.3 Gy) compared to patients with higher MHD (median PFS 32 months v. 8 months, p < 0.001; 2-year OS 69% v. 44%, p = 0.088)., Conclusion: For LA-NSCLC patients treated with CRT followed by immunotherapy, extent of cardiac irradiation may be a risk factor for immunotherapy discontinuation, disease recurrence, and death., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Purpose: Financial toxicity (FT) is a significant concern for patients with cancer. We reviewed prospectively collected data to explore associations with FT among patients undergoing concurrent, definitive chemoradiation therapy (CRT) within a diverse, urban, academic radiation oncology department., Methods and Materials: Patients received CRT in 1 of 3 prospective trials. FT was evaluated before CRT (baseline) and then weekly using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire Core-30 questionnaire. Patients were classified as experiencing FT if they answered ≥2 on a Likert scale question (1-4 points) asking if they experienced FT. Rate of change of FT was calculated using linear regression; worsening FT was defined as increase ≥1 point per month. χ 2 , t tests, and logistic regression were used to assess predictors of FT., Results: Among 233 patients, patients attended an average of 9 outpatient and 4 radiology appointments over the 47 days between diagnosis and starting CRT. At baseline, 52% of patients reported experiencing FT. Advanced T stage (odds ratio, 2.47; P  = .002) was associated with baseline FT in multivariate analysis. The mean rate of FT change was 0.23 Likert scale points per month. In total, 26% of patients demonstrated worsening FT during CRT. FT at baseline was not associated with worsening FT ( P  = .98). Hospitalization during treatment was associated with worsening FT (odds ratio, 2.30; P  = .019) in multivariate analysis., Conclusions: Most patients reported FT before CRT. These results suggest that FT should be assessed (and, potentially, addressed) before starting definitive treatment because it develops early in a patient's cancer journey. Reducing hospitalizations may mitigate worsening FT. Further research is warranted to design interventions to reduce FT and avoid hospitalizations., (© 2022 The Authors.)

Introduction: Radical prostatectomy (RP) is a standard treatment modality for localized prostate cancer. Biochemical failure after RP is usually evaluated with whole-body imaging to exclude distant metastatic disease, and pelvic magnetic resonance imaging (MRI) to detect local recurrence in the prostatectomy bed. The goal of this study is to correlate disease characteristics and demographic data in patients with rising prostate-specific antigen (PSA) after RP to determine association with MRI-detected cancer recurrence., Methods: Sixty-four patients who underwent pelvic MRI for rising PSA after RP and had complete clinical and pathological data available were included. Using Chi-squared testing, we analyzed PSA levels, pathological disease characteristics (prostate cancer risk group, Gleason score, extracapsular extension, positive surgical margin, seminal vesicle involvement, perineural invasion, lymphovascular invasion, and PSA level before MRI), time from surgery to biochemical failure, and patient demographic characteristics as potential predictors of MRI-detected local recurrence., Results: Definite MRI-detected local recurrence was observed in 17/64 patients (27%). Eleven (17%) patients had a suspicious lesion with the differential of scarring, retained seminal vesicle, or recurrent cancer. Thirty-six (56%) patients had no evidence of tumor in the prostate bed or pelvis on MRI. Patient race was associated with likelihood of detecting a prostate nodule on MRI (p=0.04), with African American patients having 82% lower odds of MRI-detected tumor recurrence compared with white patients (p=0.045). No other tumor or patient characteristic was significantly associated with MRI-detected recurrence., Conclusions: African American patients with biochemical failure after RP are less likely to have MRI-detectable recurrence in the prostate bed compared with white patients.

Aim: Financial toxicity (FT) describes patients' burden from out-of-pocket medical treatment costs. We studied associations between patient-reported pretreatment FT, socioeconomic status and clinical outcomes for locally advanced non-small-cell lung cancer (LA-NSCLC) patients. Methods: Patients received chemoradiotherapy for locally advanced non-small-cell lung cancer and completed the European Organization for the Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) quality of life assessment before treatment. One question asks whether patients experience 'financial difficulties'. We tested FT and socioeconomic status (SES) as predictors of progression-free survival (PFS) and overall survival (OS). Results: A total of 43 patients were included. Median follow-up for surviving patients was 15 months. A total of 19 patients (44%) experienced disease progression and 17 patients (40%) died. Increasing FT was associated with shorter PFS (p = 0.011). FT did not predict overall survival (p = 0.67). Conclusion: Higher pretreatment FT is associated with shorter PFS.

Background and Purpose: To assess the dosimetric flexibility of a dual balloon brachytherapy applicator developed for the treatment of anorectal lesions., Materials and Methods: Different amounts of water were infused into the inner and outer balloon separately to study the asymmetrical distribution of the catheter, the radial distance of the active source channel to the inner surface of the global target volume , the space between the active source channels, and their dosimetric impact to target tissues and uninvolved rectum., Results: Increasing inner balloon volume directly increased both the space between the active source channels and the radial distance of the active source channel to the inner surface of the global target volume. The space between the active source channels and the percentage of global target volume received 150% or more of the prescribed dose to target had a strong inverse correlation (-0.881/ P = .007, -0.976/ P = .001, respectively) with the radial distance of the active source channel to the inner surface of the global target volume. Conformity index, dose to 2 cm 3 of rectum, and total reference air kerma were strongly correlated with the radial distance of the active source channel to the inner surface of the global target volume, with values of 0.952 ( P = .001), 0.833 ( P = .015), and 0.922 ( P = .002), respectively. Percentage of global target volume received 150% or more of the prescribed dose was significantly correlated with the space between the active source channels (0.81/ P = .022), and conformity index was strongly inversely correlated with the space between the active source channels (-0.833/ P = .015)., Conclusion: The dual balloon-constructed Anorectal Applicator offers a flexible way to adjust the distances of the active source positions to the target in relation to uninvolved rectal wall. This flexibility simplifies planning which results in a highly conformal dose distribution to the target lesion while minimizing dose to normal rectal tissue.

Purpose: This study assessed the modeled probability of tumor control and organ at risk toxicities in locally advanced cervical cancer in patients treated by external beam radiation plus brachytherapy using intracavitary combined with interstitial brachytherapy (IC/IS) vs. intracavitary brachytherapy (IC) alone., Material and Methods: Twenty cervical cancer patients with a mean HR-CTV volume of 47.4 cm 3 and a mean width of 54 mm were planned with both IC/IS and IC brachytherapy alone. A probit model was utilized to model 3-year (3-yr) local control rate (LC), 3-yr cancer specific survival rate (CSS), and the adverse effect (AE) of the organ at risk by using a modeled data set from multiple institutions. Modeling results were used to estimate the LC, CSS, and AE of the treatments in this study., Results: Using the IC/IS technique, an EQD 2 increase of 12.3 Gy to D 90 (from 76.1 Gy to 88.3 Gy) of HR-CTV is expected to increase 3-yr LC and 3-yr CSS by 12.5%, and 11.0%, respectively. Comparing IC/IS to IC alone, the expected G2 + AE were 7.7% vs. 7.9% for the bladder, and 5.9% vs. 6.8% for the rectum., Conclusions: The IC/IS technique improved dose coverage to the HR-CTV without significantly increasing dose to 2 cm 3 of the organ at risk (OAR) surrounding it. With different regimens of EBRT combined with BT, IC/IS can be used to increase the probability of LC and CSS, or decrease the risk of AE.

An efficient and simple class solution is proposed for hippocampal-avoidance whole-brain radiation therapy (HA-WBRT) planning using the Volumetric Arc Therapy (VMAT) delivery technique following the NRG Oncology protocol NRG-CC001 treatment planning guidelines. The whole-brain planning target volume (PTV) was subdivided into subplanning volumes that lie in plane and out of plane with the hippocampal-avoidance volume. To further improve VMAT treatment plans, a partial-field dual-arc technique was developed. Both the arcs were allowed to overlap on the in-plane subtarget volume, and in addition, one arc covered the superior out-of-plane sub-PTV, while the other covered the inferior out-of-plane subtarget volume. For all plans (n = 20), the NRG-CC001 protocol dose-volume criteria were met. Mean values of volumes for the hippocampus and the hippocampal-avoidance volume were 4.1 cm(3) ± 1.0 cm(3) and 28.52 cm(3) ± 3.22 cm(3), respectively. For the PTV, the average values of D(2%) and D(98%) were 36.1 Gy ± 0.8 Gy and 26.2 Gy ± 0.6 Gy, respectively. The hippocampus D(100%) mean value was 8.5 Gy ± 0.2 Gy and the maximum dose was 15.7 Gy ± 0.3 Gy. The corresponding plan quality indices were 0.30 ± 0.01 (homogeneity index), 0.94 ± 0.01 (target conformality), and 0.75 ± 0.02 (confirmation number). The median total monitor unit (MU) per fraction was 806 MU (interquartile range [IQR]: 792 to 818 MU) and the average beam total delivery time was 121.2 seconds (IQR: 120.6 to 121.35 seconds). All plans passed the gamma evaluation using the 5-mm, 4% criteria, with γ > 1 of not more than 9.1% data points for all fields. An efficient and simple planning class solution for HA-WBRT using VMAT has been developed that allows all protocol constraints of NRG-CC001 to be met., (Copyright © 2015 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the variations of multi-lumen balloon (MLB)-based brachytherapy from simulation day to treatment day and their dosimetric impacts during accelerated partial breast irradiation (APBI)., Material and Methods: A total of 42 CT images scanned from seven patients were evaluated with regards to daily variation due to of: 1) internal uncertainty: size and shape of balloon, seroma volume; 2) geometrical uncertainty-random: length of each catheter was measured for each fraction (total 70); 3) geometrical uncertainty-systematic: virtual systematic errors were tested by offsetting dwell positions. The original plans (as group A) had a mean value of 96.8% on V95 of the PTV&#95;Eval. Plans were rerun (as group B) such that the mean value of the V95 was relaxed to 90.4%. By applying the reference plan to each daily CT image, variations of target coverage under different sources of error were evaluated., Results: Shape and size of the balloon had means of < 1 mm decreased in diameter and < 0.4 cm(3) decreased in volume; the mean seroma volume increased by 0.2 cm(3). This internal variation has a mean of < 1% difference for both V90 and V95. The geometrical uncertainty made a mean deviation of 2.7 mm per root of sum of square. It caused the degradations of V90 and V95 by mean values of 1.0% and 1.2%, respectively. A systematic error of 3 mm and 4 mm would degrade both of V90 and V95 by 4% and 6%, respectively. The degradations on target coverage of the plans in group A were statistically the same as those in group B., Conclusions: Overall, APBI treatments with MLB based brachytherapy are precise from day to day. However, minor variation due to daily treatment uncertainties can still degrade tumor bed coverage to an unacceptable coverage when V95 of the original plan is close to 90%.

Purpose: Controversy exists whether the prostate-specific antigen (PSA) bounce phenomenon following definitive radiation for prostate cancer has prognostic significance. Here, we perform a meta-analysis to determine the association between PSA bounce and biochemical control after brachytherapy alone., Material and Methods: We reviewed Medline, EMBASE, and CENTRAL citations through February 2012. Studies that recorded biochemical failure rates in bouncers and non-bouncers were included. Hazard ratios describing the impact of bounce on biochemical failure were extracted directly from the studies or calculated from survival curves. Pooled estimates were obtained using the inverse variance method. A random effects model was used in cases of significant effect heterogeneity (p < 0.10 using Q test)., Results: The final analysis included 3011 patients over 6 studies treated with brachytherapy. Meta-analysis revealed that patients experiencing PSA bounce after brachytherapy, conferred a decreased risk of biochemical failure (random effects model HR = 0.42, 95% CI: 0.30-0.59; p < 0.001)., Conclusions: Our meta-analysis determined that PSA bounce predicts for improved biochemical control following brachytherapy. To our knowledge, this is the first study describing this effect.

Purpose: To study the influence of timing of postseed implant imaging on rectal dose-volume parameters for cesium-131 ((131)Cs) seed prostate implants., Methods and Materials: Fifteen patients were treated in our institution with combination (131)Cs brachytherapy followed by pelvic external beam radiation therapy for intermediate to high-risk prostate cancers. For all patients, CT scans were scheduled at 7 days (CT(7)) and again at 2 months for external beam radiation therapy simulation purpose (CT(60)) postseed implantation. Comprehensive postseed implant dosimetry was performed for both CT(7) and CT(60) scans. In each case, dose-volume histogram parameters, rectal separation (the distance between the center of posterior most seed and most anterior rectal wall), and posterior row activity (the total activity implanted within 2-4mm anterior to the posterior wall of the prostate) data were collected. The absolute rectal volumes receiving 100% and 110% prescription dose were also collected., Results: Rectal dose correlated strongly with rectal separation (p<0.001). The mean change in rectal separation between CT(7) and CT(60) scans was 1.1 (±1.7) mm, and the corresponding change in 0.1-cc rectal dose was 18 (±26.5) Gy. Posterior row activity did not correlate with rectal dose (p=0.51). The mean volume of rectum that receives between 100% and 110% of the prescription dose (RV(100) and RV(110)) increased twofold, between CT(7) and CT(60) evaluations (0.03 [±0.06] cc vs. 0.07 (±0.05) cc, respectively, p=0.06)., Conclusions: Our study has demonstrated that rectal doses after (131)Cs seed implants are influenced by the timing of postseed imaging. This may be a consequence of prostatic and periprostatic edema resolution., (Copyright © 2012 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To perform a dosimetric comparison between a pre-planned technique and a pre-plan based intraoperative technique in prostate cancer patients treated with I-125 permanent seed implantation., Material and Methods: Thirty patients were treated with I-125 permanent seed implantation using TRUS guidance. The first 15 of these patients (Arm A) were treated with a pre-planned technique using ultrasound images acquired prior to seed implantation. To evaluate the reproducibility of the prostate volume, ultrasound images were also acquired during the procedure in the operating room (OR). A surface registration was applied to determine the 6D offset between different image sets in arm A. The remaining 15 patients (Arm B) were planned by putting the pre-plan on the intraoperative ultrasound image and then re-optimizing the seed locations with minimal changes to the pre-plan needle locations. Post implant dosimetric analyses included comparisons of V(100)(prostate), D(90)(prostate) and V(100)(rectum)., Results: In Arm A, the 6D offsets between the two image sets were θ(x)=-1.4±4.3; θ(y)=-1.7±2.6; θ(z)=-0.5±2.6; X=0.5±1.8 mm; Y=-1.3±-3.5 mm; Z=-1.6±2.2 mm. These differences alone degraded V(100) by 6.4% and D(90) by 9.3% in the pre-plan, respectively. Comparing Arm A with Arm B, the pre-plan based intraoperative optimization of seed locations used in the plans for patients in Arm B improved the V(100) and D(90) in their post-implant studies by 4.0% and 5.7%, respectively. This was achieved without significantly increasing the rectal dose (V(100)(rectum))., Conclusions: We have progressively moved prostate seed implantation from a pre-planned technique to a pre-plan based intraoperative technique. In addition to reserving the advantage of cost-effective seed ordering and efficient OR implantation, our intraoperative technique demonstrates increased accuracy and precision compared to the pre-planned technique.

Advances in diagnostic and therapeutic technology have not appreciably changed the outlook of patients with pancreatic cancer. While those patients presenting with localized resectable disease have the best prognosis, local control and intra-abdominal metastases remain significant obstacles to survival. Localized chemoradiation has modestly improved median survival in localized and locally advanced disease. Patients presenting with locally advanced disease at diagnosis benefit from surgical palliation which includes biliary and gastric bypass. Intraoperative interstitial brachytherapy has been effective when utilized at laparotomy to improve local control in locally advanced disease. Advances in laparoscopic techniques have provided the ability to more accurately stage patients prior to laparotomy and perform palliative procedures without the need for laparotomy. The utilization of high-dose-rate brachytherapy has proven effective in palliating obstructive symptoms with minimal morbidity on an outpatient basis. Recent efforts have focused on preoperative chemoradiation to improve resectability in selected patients and prophylactic hepatic irradiation to reduce metastases for patients with locally advanced disease.

The use of brachytherapy in the management of adult soft tissue sarcomas of the extremities has been applied in combination with conservative surgery in an attempt to avoid amputation. Retrospective studies and a single prospective trial currently underway suggest that this combination is highly effective in improving local control for high-grade tumors, independent of size, location in the extremity, and depth. However, no effect has been shown in preventing distant metastases, or in prolonging survival in high-grade tumors. Likewise, no effect has been documented on low-grade tumors. Whether adjuvant chemotherapy can improve overall and disease-free survival remains debatable. New innovative brachytherapy approaches are being investigated to eliminate radiation exposure associated with the use of low-dose-rate Iridium-192 (Ir-192), and to further improve the treatment results in all tumor grades.

In the period November 1991 to October 1993 altogether 418 patients underwent laparoscopic cholecystectomy in our unit. Routine intraoperative cholangiography, a prerequisite for diagnosing choledocholithiasis, was successful in 99.3% of cases. 38 patients were found to have common bile duct calculi and their management and follow up are reported in this study. In 36 cases stones were successfully eliminated by means of the laparoscopic procedure, via the cystic duct in 22 cases and by choledochotomy in 14 cases. One patient required postoperative endoscopic papillotomy, and in the remaining case surgical management was changed to classical laparotomy and open choledochotomy. Postoperative complications occurred in five cases. One patient suffering from bacterial peritonitis underwent laparotomy on the 9th postoperative day, another with postoperative bleeding from the cystic artery was relaparoscopied on the same day as the minimal invasive procedure. One patient developed a liver abscess three weeks after operation, requiring drainage with the aid of ultrasound. A superficial wound infection in one patient and biliary leakage after removal of the T-tube in another patient both healed spontaneously. Our results are similar to those obtained with other therapeutic concepts. Because the papilla of Vater remains intract in minimal invasive surgery, which causes relatively little stress to the patient, as well as considering the economic advantages of a single-step procedure, this management strategy can be recommended as a valuable alternative procedure.

The momentum brought about by the expansion in the field of minimally invasive surgery (MIS) and the endeavor of many surgeons to apply this operative technique, raises both quantitative as well as qualitative problems as far as the training in minimally invasive surgery is concerned. In the respective courses the training usually begins with synthetic dummies and/or animal organs in the simulation trainer. In the next - and already last - step before the clinical operation, the procedure is practiced on anesthetized animals. The wide gap between basic training and the animal experiment is filled by the Pulsatile Organ Perfusion (POP). POP simulates blood supply of organs or organsystems ideally and therefore it is the ideal method for completing training in laparoscopic and thoracoscopic techniques as this method would be used at any hospital or laboratory. The quality of simulating operations is excellent, the method is cost-effective and does not require the expense and infrastructure of the experimental animal laboratory. Furthermore the amount of animals required for advanced MIS-training will be greatly reduced.