Unforeseen Computed Tomography Resimulation for Initial Radiation Planning: Associated Factors and Clinical Impact

Purpose: Repeat computed tomography (CT) simulation is problematic because of additional expense of clinic resources, patient inconvenience, additional radiation exposure, and treatment delay. We investigated the factors and clinical impact of unplanned CT resimulations in our network. Methods and Materials: We used the billing records of 18,170 patients treated at 5 clinics. A total of 213 patients were resimulated before their first treatment. The disease site, location, use of 4- dimensional CT (4DCT), contrast, image fusion, and cause for resimulation were recorded. Odds ratios determined statistical significance. Results: Our total rate of resimulation was 1.2%. Anal/colorectal (P \u3c .001) and head and neck (P \u3c .001) disease sites had higher rates of resimulation. Brain (P Z .001) and lung/thorax (P Z .008) had lower rates of resimulation. The most common causes for resimulation were setup change (11.7%), change in patient anatomy (9.8%), and rectal filling (8.5%). The resimulation rate for 4DCTs was 3.03% compared with 1.0% for non-4DCTs (P \u3c .001). Median time between simulations was 7 days. Conclusions: The most common sites for resimulation were anal/colorectal and head and neck, largely because of change in setup or changes in anatomy. The 4DCT technique correlated with higher resimulation rates. The resimulation rate was 1.2%, and median treatment delay was 7 days. Further studies are warranted to limit the rate of resimulation

Stereotactic Body Radiotherapy (SBRT) for Oligometastatic Lung Nodules: A Single Institution Series

Aim: Lung metastases from an extra-pulmonary origin occasionally present with a limited metastatic disease burden. In cases where metastatectomy is not feasible, stereotactic body radiation therapy (SBRT) represents a non-invasive, efficacious option. We report the outcomes of patients treated with lung SBRT in cases of limited metastatic disease.Methods: We retrospectively reviewed outcomes in 44 patients with 50 lung nodules from various extra-pulmonary malignancies treated with SBRT. Fifty percent of the patients were male and median age was 64. The median number of nodules was 1 and 90% of patients had oligometastatic disease. Thirty-four percent of patients had extra-thoracic disease.Results: Fifty lung nodules were treated with SBRT in 44 patients. Median dose was 48 Gy in 5 fractions with a median biological effective dose (BED) of 100 Gy10. Follow-up imaging was available for review in 96% of nodules. Median follow-up was 17.5 months. One year local control was 82%. BED >72 Gy10 predicted improved local control (90 vs. 57% at 1 year). One year overall survival following SBRT was 66%. There was no difference in overall survival if patients had extra-thoracic disease.Conclusion: Lung SBRT is a safe, effective tool for treatment of limited lung metastases. Dose selection remains important for local control

Prospective evaluation of patient-reported outcomes of invisible ink tattoos for the delivery of external beam radiation therapy: the PREFER trial

IntroductionInvisible ink tattoos (IITs) avoid cosmetic permanence of visible ink tattoos (VITs) while serving as more reliable landmarks for radiation setup than tattooless setups. This trial evaluated patient-reported preference and feasibility of IIT implementation.Methods and materialsIn an IRB-approved, single institution, prospective trial, patients receiving proton therapy underwent IIT-based treatment setup. A survey tool assessed patient preference on tattoos using a Likert scale. Matched patients treated using our institutional standard tattooless setup were identified; treatment times and image guidance requirements were evaluated between tattooless and IIT-based alignment approaches. Distribution differences were estimated using Wilcoxon rank-sum tests or Chi-square tests.ResultsOf 94 eligible patients enrolled, median age was 58 years, and 58.5% were female. Most common treatment sites were breast (18.1%), lung (17.0%) and pelvic (14.9%). Patients preferred to receive IITs versus VITs (79.8% pre-treatment and 75.5% post-treatment, respectively). Patients were willing to travel farther from home to avoid VITs versus IITs (p<0.01). Females were willing to travel (45.5% vs. 23.1%; p=0.04) and pay additional money to avoid VITs (34.5% vs. 5.1%; p<0.01). Per-fraction average +treatment time and time from on table/in room to first beam were shorter with IIT-based vs. tattooless setup (12.3min vs. 14.1min; p=0.04 and 24.1min vs. 26.2min; p=0.02, respectively).DiscussionIn the largest prospective trial on IIT-based radiotherapy setup to date, we found that patients prefer IITs to VITs. Additionally, IIT-based alignment is an effective and efficient strategy in comparison with tattooless setup. Standard incorporation of IITs for patient setup should be strongly considered

THE ROLE OF POSTOPERATIVE RADIATION AND CHEMORADIATION IN MERKEL CELL CARCINOMA: A SYSTEMATIC REVIEW OF THE LITERATURE

Objective. A systematic review of the literature was undertaken to investigate whether adjuvant radiotherapy and/or chemotherapeutics offered any additional benefit than surgery alone. Background. Merkel cell carcinoma (MCC) is a relatively rare cutaneous malignancy with a high recurrence and mortality rate. Few recommendations exist for the treatment of MCC, but the general consensus is the surgical excision as the initial treatment. However, postoperative use of adjuvant radiotherapy and/or chemotherapeutics remains unclear. Methods. A PubMed, MEDLINE search was conducted between 1995-2013, to identify reported cases of surgically treated MCC. Patient characteristics that were extracted include age, gender, size and location of primary tumor, clinical stage and nodal involvement. Assessment of outcomes were reviewed and reported as overall survival (OS), OS after one year, three years, local control (LC) after one year, three years, crude recurrence, time to recurrence and toxicity. Inclusion criteria included a primary tumor of MCC in any stage, positive or negative metastases to lymph nodes, lesions of any size, and primary treatment that included curative surgery followed by observation, radiation within 3 months, or chemoradiation within 3 months. A subset analysis was performed contrasting observation and RT treatments based on the mean tumor size for the study. Results. 34 studies (n = 4475) were included. The median age was 73 years, median follow-up was 36 months and there was a 1.5:1 ratio of men to women. All 4475 patients had surgery, 1975 had no further treatment, 1689 received postoperative RT, and 301 received postoperative chemoRT. The most common primary site was face/head/neck, 47.8%. Stage 1 was the most common clinical stage at diagnosis (57%), though it was not equally represented in each cohort. 3-year LC was found to be 20% [median 10%] in the observation cohort, compared to 65% [62%] with postoperative RT and 67% [75%] with postoperative chemoRT; these findings were statistically significant (P \u3c 0.001). Recurrence was found to be 38% [60%] in the observation cohort, compared to 23% [20%] with postoperative RT; this was statistically significant (P \u3c 0.001). 3-year OS was found to be 56% [57%] in the observation cohort, compared to 70% [78%] with postoperative RT and 73% [76%] with postoperative chemoRT; these findings were statistically significant (P \u3c 0.001). The observation cohort had a median OS of 44 months compared with 64 months (P \u3c 0.001) in the postoperative RT cohort. There was n

The role of postoperative radiation and chemoradiation in Merkel Cell Carcinoma: A systematic review of the literature

Objective: A systematic review of the literature was undertaken to investigate whether adjuvant radiotherapy and/or chemotherapeutics offered any additional benefit than surgery alone in the treatment of Merkel Cell Carcinoma (MCC). Methods: A PubMed, MEDLINE search was conducted between 1995-2013, to identify reported cases of surgically treated MCC followed by either observation, radiation, or chemoradiation. Patient demographics and outcomes were recorded and compared in a systematic fashion. Results: Thirty-four studies (n = 4475) were included. The median age was 73 years, median follow-up was 36 months and there was a 1.5:1 ratio of men to women. All 4475 patients had surgery, 1975 had no further treatment, 1689 received postoperative RT, and 301 received postoperative chemoRT. The most common site was face/head/neck, 47.8%. Stage 1 was the most common clinical stage at diagnosis (57%). Three-year LC was 20% [median 10%] in the observation cohort, compared to 65% [62%] with postoperative RT and 67% [75%] with postoperative chemoRT; these findings were statistically significant (

A 58-Year-Old Woman with Left-Sided Weakness and a History of a Pediatric Brain Tumor: A Case Report

Background: An uncommon but well-established complication of cranial irradiation is secondary neoplasm. This case presentation documents a radiation-induced malignant glioma 55 years after being diagnosed with “cerebral sarcoma,” now defined as atypical meningioma. This not only represents the longest reported latency period for a patient initially receiving over 30 Gy, but also provides a valuable historical perspective of neuro-oncology. Clinical Presentation: A 58-year-old female presenting with progressive left-sided upper and lower extremity weakness with a past medical history significant for “cerebral sarcoma” was diagnosed with glioblastoma multiforme. This patient had previously been treated with resection and adjuvant radiation therapy via a 280-kVP orthovoltage machine and received 3,390 rad to the posterior three-quarters of the skull for “cerebral sarcoma.” Conclusion: A comprehensive investigation of the past medical history helped uncover a mysterious pediatric diagnosis, helped drive the management 5 decades later, and serves as a reminder that seemingly safe interventions may still cause harm