IntroductionThe Institute of Medicine, the American Society of Clinical Oncology, and the European Society of Medical Oncology promote a multidisciplinary approach for the treatment of cancer. Stage III non-small-cell lung cancer (NSCLC) represents a heterogeneous group of diseases necessitating coordination of care among medical, radiation, and surgical oncology. The optimal care of stage III NSCLC underscores the need for a multidisciplinary approach.MethodsFrom tumor registry data, we identified all cases of stage III NSCLC seen at Lehigh Valley Health Network between March 2010 and March 2013. The care received by patients when seen in the thoracic multidisciplinary clinic (MDC) was compared with the care received when not seen in the thoracic MDC.ResultsAll patients seen in the MDC, compared to <50% of patients seen outside the MDC, were evaluated by more than one physician prior to beginning the treatment. Time to initiate treatment was shorter in MDC patients than in non-MDC patients. Patients seen in the MDC had a greater concordance with clinical pathways. A greater percentage of patients seen in the thoracic MDC had pathologic staging of their mediastinum. Patients seen in the MDC were more likely to receive all of their care at Lehigh Valley Health Network.ConclusionMultidisciplinary care is essential in the treatment of patients with stage III NSCLC. Greater utilization of MDCs for this complex group of patients will result in more efficient coordination of care, pretreatment evaluation, and therapy, which in turn should translate to improve patients’ outcomes.
Purpose/Objective(s)
Conformal radiation therapy in the post-prostatectomy setting requires accurate setup and localization of the prostatic fossa. In this series, we report prostate bed localization and motion characteristics using data collected from implanted radiofrequency transponders.
Materials and Methods
The Calypso 4D Localization System uses three implanted radiofrequency transponders for daily target localization and real-time tracking throughout a course of radiation therapy. We reviewed the localization and tracking reports of 20 patients who received ultrasound-guided placement of Calypso transponders within the prostate bed prior to a course of intensity modulated radiation therapy at Fox Chase Cancer Center.
Results
At localization, prostate bed displacement relative to bony anatomy exceeded 5 mm in 9% of fractions in the Anterior-Posterior (A-P) direction, and 21% of fractions in the Superior-Inferior (S-I) direction. The three-dimensional vector length from skin marks to Calypso alignment exceeded 1 cm in 24% of all 652 fractions with available setup data. During treatment, the target exceeded the 5 mm tracking limit for at least 30 seconds in 11% of all fractions, generally in the A-P or S-I directions. In the A-P direction, target motion was twice as likely to move posteriorly, towards the rectum, than anteriorly. 15% of all treatments were interrupted for repositioning, and 70% of patients were repositioned at least once during their treatment course.
Conclusion
Set-up errors and motion of the prostatic fossa during radiotherapy are nontrivial, leading to potential undertreatment of target and excess normal tissue toxicity if not taken into account during treatment planning. Localization and real-time tracking of the prostate bed via implanted Calypso transponders can be used to improve the accuracy of plan delivery.
Purpose
This is a retrospective analysis of the impact of moderate dysplasia at the resection margin for early stage cancer of the oral tongue.
Materials and Methods
Patients with T1-2N0 oral tongue cancer treated with surgery alone at Fox Chase Cancer Center (FCCC) from 1990 – 2010 were reviewed. Tumor and margin characteristics were abstracted from the pathology report.
Overall survival (OS), disease-free survival (DFS) and local control (LC) were calculated using the Kaplan Meier method. Predictors of LC, OS and DFS were analyzed.
Results
126 patients met the inclusion criteria. Dysplasia was present at the final margin in 36% of the cases (severe: 9%, moderate: 15%, mild: 12%).
Median follow-up was 52 months. 3 and 5-year actuarial LC for the entire cohort was 77 and 73%, respectively. Actuarial 5-year LC and DFS were significantly worse for patients with moderate or severe dysplasia at the margin vs. none or mild dysplasia at the margin (49 v 82%, p = 0.005 and 49 v 80%, p = 0.008, respectively); 3-year comparisons were not significant. When analyzed separately, the detrimental local effect of moderate dysplasia at the margin persisted (p = 0.02) and the effect of severe dysplasia at the margin was approaching significance (p = 0.1). Mild dysplasia at the margin did not significantly impair LC or DFS.
Multivariate analysis demonstrated worse LC (HR: 2.99, p=0.006) and DFS (HR: 2.84, p=0.008) associated with severe or moderate dysplasia at the margin.
Conclusions
Both severe and moderate dysplasia at the margin appear to be correlated with inferior LC and DFS. Additional therapy may be justified, despite added morbidity.
Purpose
Large breast size presents special problems during radiation simulation, planning and patient treatment, including increased skin toxicity, in women undergoing breast-conserving surgery and radiotherapy (BCT). We report our experience using a bra during radiation in large-breasted women and its effect on acute toxicity and heart and lung dosimetry.
Materials and methods
From 2001 to 2006, 246 consecutive large-breasted women (bra size ≥ 38 and/or ≥ D cup) were treated with BCT using either 3D conformal (3D-CRT) or Intensity Modulated Radiation (IMRT). In 58 cases, at the physicians’ discretion, a custom-fit bra was used during simulation and treatment. Endpoints were acute radiation dermatitis, and dosimetric comparison of heart and lung volumes in a subgroup of 12 left-sided breast cancer patients planned with and without a bra.
Results
The majority of acute skin toxicities were grade 2 and were experienced by 90% of patients in a bra compared to 70% of patients not in a bra (p=0.003). On multivariate analysis significant predictors of grade 2/3 skin toxicity included 3D-CRT instead of IMRT (OR=3.9, 95% CI:1.8-8.5) and the use of a bra (OR=5.5, 95% CI:1.6-18.8). For left-sided patients, use of a bra was associated with a volume of heart in the treatment fields decreased by 63.4% (p=0.002), a volume of left lung decreased by 18.5% (p=0.25), and chest wall separation decreased by a mean of 1 cm (p=0.03).
Conclusions
The use of a bra to augment breast shape and position in large-breasted women is an alternative to prone positioning and associated with reduced chest wall separation and reduced heart volume within the treatment field.
Objectives
To evaluate erectile function following high dose radiotherapy for prostate cancer using the international index of erectile function (IIEF), expanded prostate cancer index composite (EPIC), and stamp test.
Methods
Men with favorable and intermediate risk prostate cancer were assigned to receive prostate intensity modulated radiotherapy (IMRT) vs. an erectile tissue-sparing IMRT technique on a phase III randomized prospective study. The stamp test, IIEF, and EPIC questionnaires were completed at baseline, 6 months, one year, and two years after IMRT. Sexual Health Inventory for Men (SHIM) scores were abstracted from IIEF questionnaires. A partner questionnaire, designated IIEF-P, modeled after the IIEF but from the perspective of the partner, was collected.
Results
Ninety four men enrolled on the trial who completed at least one questionnaire or one stamp test were analyzed. The median age of the patient population was 62.5 years. The median RT dose was 76 Gy (range: 74–80 Gy). At 6-months and one year after high-dose IMRT, a positive stamp result significantly correlated with median EPIC sexual summary, sexual function (EF), and bother subscale scores. Additionally, 6-months after IMRT the stamp test correlated with median IIEF, IIEF EF domain, and SHIM scores. Robust concordance for the IIEF and SHIM results was appreciated between responding patients: partner pairs.
Conclusions
Nocturnal tumescence indicated by a positive stamp test correlates well with established quality of life questionnaires after IMRT. The stamp test should strongly be considered as an objective measure of erectile function in future studies of ED in prostate cancer patients.
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