In this population-based study, there were no urban-rural differences in access to multidisciplinary care, but increased distance may be associated with worse cancer-specific outcomes.

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PurposeWhole brain radiation therapy (WBRT) remains the standard of care for patients with multiple brain metastases, but more than half of treated patients will develop intracranial progression. Because there is no clear consensus on the optimal therapeutic approach, a prognostic index would be helpful to guide treatment options at progression. We explored whether the recursive partitioning analysis (RPA) score prior to repeat WBRT is predictive of survival.Methods and materialsThis multi-institutional pooled analysis included patients with 2 or more brain metastases from any solid primary tumor that was treated with 2 courses of WBRT. Information on demographics, disease characteristics, and intervals between courses was collected. RPA class was abstracted or retrospectively assigned, and descriptive statistics calculated. Median survival (MS) was determined using the Kaplan-Meier method and compared using log rank tests. Univariate and multivariate analyses were performed via Cox regression analysis.ResultsFor 205 patients, the median age was 55 years (range, 25-83 years), 68% were female, 40.5% had non-small cell lung cancer, and 31.2% had small cell lung cancer. Prior to the second WBRT, 4.9% of patients were RPA class 1, 36.6% were RPA2, and 58.5% were RPA3, with an MS of 7.5 months (95% confidence interval [CI], 4.7-10.3), 5.2 months (95% CI, 3.7-6.7 months), and 2.9 months (95% CI, 2.2-2.9 months), respectively (P = .001). On univariate and multivariate analyses, a Karnofsky Performance Status of <80, extracranial metastases, interval between courses <9 months, small cell lung cancer histology, and uncontrolled primary significantly correlated with shorter MS. By assigning a score of 1 to each of these factors, a new prognostic index was created, the reirradiation (ReRT) score. Survival on the basis of ReRT score grouping ranged from 2.2 to 7.2 months and demonstrated significant differences in MS.ConclusionsIn the largest reported cohort to receive repeat WBRT, application of the RPA score was not predictive of MS. The new ReRT score is a simple tool based on readily available clinical information.

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Mantle cell lymphoma is an aggressive B-cell lymphoma for which the biology is incompletely understood. Previous studies have reported that somatic hypermutation of the variable region of the immunoglobulin heavy chain gene (V H ), as commonly defined as o98% homology, can be detected in approximately one-third of mantle cell lymphoma, although the V H mutation status has not been found to significantly correlate with patient survival. In this study, we assessed V H mutation in 55 mantle cell lymphomas using a method slightly different from those used in the previous studies, and we came to different conclusions. Using DNA extracted from formalin-fixed/paraffin-embedded tumors in all cases, we identified monoclonal IGH bands in 54 of 55 cases with the FR1c/J H primer; a monoclonal IGH band was amplified using another IGH primer set, FR256/J H , in the remaining case. Cloning was performed in all cases, and an average of six clones were sequenced and analyzed for each case. Intraclonal heterogeneity was detected in 45 (82%) cases. Further analysis was performed in 53 cases, in which a predominant IGH species was identified. Most (32 of 53 cases, 60%) cases were 'mutated', with o98% homology. V H 1-69, V H 4-59 and V H 3-74 were utilized in 29 (55%) cases. Intraclonal evolution and nonproductive V H rearrangements were more frequent in the mutated group. Patients with the 'mutated' genotype had longer overall survival (P ¼ 0.017, Log rank) that is independent of the international prognostic index. To conclude, our data suggest that the V H mutation frequency in mantle cell lymphoma may be higher than previously believed. Importantly, using our methodology, we found that the V H mutation status may be a useful prognostic marker for these patients. Mantle cell lymphoma is a distinct clinicopathologic entity recognized by the World Health Organization Classification Scheme. 1 The genetic hallmark of this disease is the chromosomal abnormality, the t(11;14)(q13;q32), which results in cyclin D1 overexpression. 2 Using transgenic mouse models, two research groups have shown that enforced cyclin D1 expression in B cells is not sufficient for lymphomagenesis. 3,4 Recent studies, including a number of oligonucleotide array studies, revealed additional biochemical abnormalities in mantle cell lymphoma, such as defects in the apoptotic pathway, cell cycle progression and DNA repair. [5][6][7][8][9][10] To further understand the biology of this type of B-cell neoplasm, one approach is to examine the somatic hypermutation of the variable region of the immunoglobulin heavy chain (V H ) gene. In chronic lymphocytic leukemia, it has been shown that a subset of cases has relatively high levels of V H somatic mutation, and mutated cases were associated with better clinical outcome when using o98% homology as the cutoff. 11-14 More recently, several large studies were performed to examine the V H mutation status in mantle cell lymphoma; using o98% homology (compared to the germline sequences) as the cutoff, it was found that 29-34% of

The VARA clinic has improved wait times for palliative RT, increased patient access to supportive services, and improved the workload for lung radiation oncologists. This clinic could serve as a model for other patients with incurable cancer.

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Genitourinary malignancy presenting as an ocular metastasis: A case report and review of the literature Cite as: Can Urol Assoc J 2012;6(2):e67-71. http://dx. Abstract Metastases to the eye or orbit as the initial presentation of geni-tourinary malignancy are unusual and can be a diagnostic challenge. We report an 81-year-old man who presented with pain and proptosis in an eye that had been blind for 50 years. Radiologic investigations identified a mass involving the left globe and orbit. Histology of the enucleation specimen was consistent with a met-astatic poorly differentiated carcinoma suggestive of a prostate primary. With the constellation of obstructive urinary symptoms, an abnormal digital rectal examination, elevated prostate-specific antigen and a positive bone scan, androgen deprivation therapy was initiated for metastatic prostate cancer. After an initial response to treatment, the patient's disease progressed in a manner atypi-cal for prostate cancer. After describing our case, we review the literature on ocular and orbital metastases and their relation to genitourinary malignancies.