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Vargas CE, Laughlin BS. In Reply to Al-Rashdan. Int J Radiat Oncol Biol Phys 2024; 119:305-306. [PMID: 38631742 DOI: 10.1016/j.ijrobp.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 04/19/2024]
Affiliation(s)
- Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
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Laughlin BS, Corbin KS, Toesca DAS, Thorpe CS, Golafshar MA, Pockaj B, Cronin P, McGee LA, Halyard MY, Mutter RW, Keole SR, Park SS, Shumway DA, Vern-Gross TZ, Vallow L, Wong WW, DeWees TA, Vargas CE. Physician- and Patient-Reported Outcomes of the MC1635 Phase 3 Trial of Ultrahypofractionated Versus Moderately Hypofractionated Adjuvant Radiation Therapy After Breast-Conserving Surgery. Int J Radiat Oncol Biol Phys 2024; 118:1049-1059. [PMID: 37914139 DOI: 10.1016/j.ijrobp.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/21/2023] [Accepted: 10/14/2023] [Indexed: 11/03/2023]
Abstract
PURPOSE Our aim was to report physician- and patient-reported outcomes of patients with localized breast cancer treated with moderate versus ultrahypofractionated whole breast irradiation (WBI) after breast-conserving surgery (BCS). METHODS AND MATERIALS Between February 2018 and February 2020, patients with localized breast cancer (pT0-3 pN0-1 M0) were offered participation in a phase 3 randomized clinical trial assessing adjuvant moderate hypofractionation (MHF) to 40 Gy in 15 fractions versus ultrahypofractionation (UHF) to 25 Gy in 5 fractions after BCS, with an optional simultaneously integrated boost. Toxicities, cosmesis, and quality of life were assessed at baseline, end of treatment (EOT), and 3 months, 1 year, 2 years, and 3 years from irradiation using validated metric tools. RESULTS One hundred seven patients were randomized to MHF (n = 54) or UHF (n = 53) adjuvant WBI. The median follow-up was 42.8 months. Grade 2 radiation dermatitis was experienced by 4 patients (7.4%) in the MHF arm and 2 patients (3.7%) in the UHF arm at EOT (P = .726). No grade 3 or higher toxicities were observed. Deterioration of cosmesis by physician assessment was observed in 2 (6.7%) patients treated in the UHF arm and 1 (1.9%) patient treated in the MHF arm at EOT (P = .534), whereas at 3 months, only 1 (1.8%) patient treated in the MHF arm demonstrated deterioration of cosmesis (P = .315). At EOT, 91% and 94% of patients reported excellent/good cosmesis among those treated with MHF and UHF regimens, respectively (P = .550). At 3 months, more patients within the MHF arm reported excellent/good cosmesis compared with those in the UHF arm (100% vs 91%; P = .030). However, the difference in patient-reported cosmesis disappeared at the 1-, 2-, and 3-year time points. CONCLUSIONS UHF WBI showed similar treatment-related late toxicities and similar provider-scored cosmesis compared with MHF radiation in patients treated adjuvantly after BCS.
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Affiliation(s)
| | | | | | - Cameron S Thorpe
- Department of Radiation Oncology, Sanford Health, Fargo, North Dakota
| | - Michael A Golafshar
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Barbara Pockaj
- Department of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Patricia Cronin
- Department of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Laura Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Todd A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.
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Tegtmeier RC, Kutyreff CJ, Smetanick JL, Hobbis D, Laughlin BS, Toesca DAS, Clouser EL, Rong Y. Custom-Trained Deep Learning-Based Auto-Segmentation for Male Pelvic Iterative CBCT on C-Arm Linear Accelerators. Pract Radiat Oncol 2024:S1879-8500(24)00035-3. [PMID: 38325548 DOI: 10.1016/j.prro.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/21/2023] [Accepted: 01/11/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE The purpose of this investigation was to evaluate the clinical applicability of a commercial artificial intelligence-driven deep learning auto-segmentation (DLAS) tool on enhanced iterative cone beam computed tomography (iCBCT) acquisitions for intact prostate and prostate bed treatments. METHODS AND MATERIALS DLAS models were trained using 116 iCBCT data sets with manually delineated organs at risk (bladder, femoral heads, and rectum) and target volumes (intact prostate and prostate bed) adhering to institution-specific contouring guidelines. An additional 25 intact prostate and prostate bed iCBCT data sets were used for model testing. Segmentation accuracy relative to a reference structure set was quantified using various geometric comparison metrics and qualitatively evaluated by trained physicists and physicians. These results were compared with those obtained for an additional DLAS-based model trained on planning computed tomography (pCT) data sets and for a deformable image registration (DIR)-based automatic contour propagation method. RESULTS In most instances, statistically significant differences in the Dice similarity coefficient (DSC), 95% directed Hausdorff distance, and mean surface distance metrics were observed between the models, as the iCBCT-trained DLAS model outperformed the pCT-trained DLAS model and DIR-based method for all organs at risk and the intact prostate target volume. Mean DSC values for the proposed method were ≥0.90 for these volumes of interest. The iCBCT-trained DLAS model demonstrated a relatively suboptimal performance for the prostate bed segmentation, as the mean DSC value was <0.75 for this target contour. Overall, 90% of bladder, 93% of femoral head, 67% of rectum, and 92% of intact prostate contours generated by the proposed method were deemed clinically acceptable based on qualitative scoring, and approximately 63% of prostate bed contours required moderate or major manual editing to adhere to institutional contouring guidelines. CONCLUSIONS The proposed method presents the potential for improved segmentation accuracy and efficiency compared with the DIR-based automatic contour propagation method as commonly applied in CBCT-based dose evaluation and calculation studies.
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Affiliation(s)
- Riley C Tegtmeier
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | | | - Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona; Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | | | - Edward L Clouser
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona.
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Vern-Gross TZ, Laughlin BS, Kough K, Ernst B, Langley N, Rule WG, Patel SH, Ashman JB. Implementation of the REFLECT Communication Curriculum for Clinical Oncology Graduate Medical Education. J Palliat Med 2024; 27:231-235. [PMID: 38301158 PMCID: PMC10825284 DOI: 10.1089/jpm.2023.0316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 02/03/2024] Open
Abstract
Background: Communication and interpersonal skills are essential medical components of oncology patient care. Patients and families rely on physicians for treatment, expertise, guidance, hope, meaning, and compassion throughout a life-threatening illness. A provider's inability to empathize with patients is linked to physician-related fatigue and burnout. Because oncology training programs focus on teaching evidence-based medicine and clinical acumen, little time may be dedicated to professional development and acquisition of interactive skills. Traditional communication courses typically include two components: formal, knowledge-based learning skills, which are gained from didactic lectures, and role-playing, which usually occurs in small groups. We report the implementation of a novel longitudinal communication curriculum for trainees in Oncology. Materials and Methods: At a single-center institution, an innovative communication curriculum titled "REFLECT" (Respect, Empathy, Facilitate Effective Communication, Listen, Elicit Information, Compassion, and Teach Others) was implemented for radiation oncology residents and medical oncology fellows to improve and refine physician/patient interactions. All oncology specialty residents and fellows were eligible to participate in this communication curriculum. The curriculum emphasized a reflective process to guide trainees through challenging scenarios. Results: Since October 2018, this comprehensive course consisted of quarterly (four hour) workshops comprising assigned reading, knowledge assessments, didactic lectures, expert guest lecturers, standardized patient simulations, role-playing, patient/expert panels, coaching, reflective writing, and debriefing/feedback sessions. The curriculum provided longitudinal communication training integrated with the learners' daily physician/patient encounters rather than occasional isolated experiences. Fifteen workshops have been completed. Each focused on navigating challenging situations with patients, loved ones, or colleagues. Conclusions: Future directions of the curriculum will entail improving the communication skills of oncology trainees and gathering communication improvement data to assess the program's success formally.
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Affiliation(s)
| | - Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Katherine Kough
- Department of Humanities, Mayo Clinic, Phoenix, Arizona, USA
| | - Brenda Ernst
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Natalie Langley
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Arizona, USA
| | - William G. Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Samir H. Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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Laughlin BS, Langley N, Patel SH, Kough K, Ernst B, Ashman JB, Rule WG, Vern-Gross TZ. Attitudes and Perception of the REFLECT Communication Curriculum for Clinical Oncology Graduate Medical Education. J Cancer Educ 2023; 38:1786-1791. [PMID: 37349641 PMCID: PMC10656312 DOI: 10.1007/s13187-023-02333-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 06/24/2023]
Abstract
Communication and interpersonal skills are essential components of oncology patient care. The REFLECT (Respect, Empathy, Facilitate Effective Communication, Listen, Elicit Information, Compassion, and Teach Others) curriculum is a novel framework to improve and refine physician/patient interactions for oncology graduate medical trainees. We seek to evaluate the attitudes and perceptions of the REFLECT communication curriculum among oncology trainees. Seven-question and 8-question Likert scale surveys (1 = not beneficial and 5 = beneficial) were distributed to resident/fellow participants and faculty mentors, respectively. Questions asked trainees and faculty about their perceptions of improvement in communication, handling of stressful situations, the value of the curriculum, and overall impression of the curriculum. Descriptive statistics determined the survey's baseline characteristics and response rates. Kruskal-Wallis rank sum tests were used to compare the distribution of continuous variables. Thirteen resident/fellow participants completed the participant survey. Six (43.6%) Radiation Oncology trainees and 7 (58.3%) Hematology/Oncology fellows completed the trainee survey. Eight (88.9%) Radiation Oncologists and 1 (11.1%) Medical Oncologist completed the observer survey. Faculty and trainees generally felt that the curriculum increased communication skills. Faculty responded more favorably to the program's impact on communication skills (median 5.0 vs. 4.0, p = 0.008). Faculty were more assertive about the curriculum's capabilities to improve a learner's ability to handle stressful situations (median 5.0 vs. 4.0, p = 0.003). Additionally, faculty had a more favorable overall impression of the REFLECT curriculum than the residents/fellows (median 5.0 vs. 4.0, p < 0.001). Radiation Oncology residents felt more strongly that the curriculum enhanced their ability to handle stressful topics, compared to Heme/Onc fellows (median 4.5 vs. 3.0, range 1-5, p = 0.379). Radiation Oncology trainees felt more consistently that the workshops improved their communication skills, compared to Heme/Onc fellows (median 4.5 vs. 3.5, range 1-5, p = 0.410). The overall impression between Rad Onc resident and Heme/Onc fellows was similar (median 4.0, p = 0.586). Conclusions: Overall, the REFLECT curriculum enhanced communication skills of trainees. Oncology trainees and faculty physicians feel that the curriculum was beneficial. As interactive skills and communication is critical to build positive interactions, further work is needed to improve the REFLECT curriculum.
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Affiliation(s)
- Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA.
| | - Natalie Langley
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, AZ, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | | | - Brenda Ernst
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
| | - Tamara Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ, 85054, USA
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Laughlin BS, Anderson JD, Hobbis D, Armstrong M, Vargas CE, Rong Y, Yu NY. Energy use in moderate hypofractionation and stereotactic body radiotherapy for prostate cancer. BJU Int 2023; 132:648-650. [PMID: 37553875 DOI: 10.1111/bju.16151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Affiliation(s)
| | | | - Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Lucido JJ, Penoncello GP, Laughlin BS, Armstrong MD, Lo SG, Rivera JN, Tang X, Chungbin SJ, Breen WG, Mangold AR, Comfere NI, Lester SC, Rule WG, Deufel CL, Foster MG. Development and Dosimetric Characterization of a Customizable Shield for Subtotal Skin Electron Beam Therapy. Adv Radiat Oncol 2023; 8:101289. [PMID: 37457824 PMCID: PMC10344686 DOI: 10.1016/j.adro.2023.101289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/08/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose Purpose: Subtotal skin electron beam therapy may be an option for patients with cutaneous lymphoma receiving radiation therapy to treat large areas of their skin but may benefit from sparing specific areas that may have had previous radiation therapy, are of specific cosmetic concern, and/or show no evidence of disease. We report here on the design, implementation, and dosimetric characteristics of a reusable and transparent customizable shield for use with the large fields used to deliver total skin electron beam therapy at extended distance with a conventional linear accelerator. Methods and Materials A shield was designed and manufactured consisting of acrylic blocks that can be mounted on a steel frame to allow patient-specific shielding. The dosimetry of the device was measured using radiochromic film. Results The shield is easy to use and well-tolerated for patient treatment, providing minimal electron transmission through the shield with a sharp penumbra at the field edge, with no increase in x-ray dose. We report on the dosimetry of a commercial device that has been used to treat more than 30 patients to date. Conclusions The customizable shield is well suited to providing patient-specific shielding for subtotal skin electron beam therapy.
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Affiliation(s)
- J. John Lucido
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Stephanie G. Lo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Judith N. Rivera
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Xueyan Tang
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - William G. Breen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Scott C. Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - William G. Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Laughlin BS, Griffeth EM, Bush AF, Albold CA, Boes CJ, Sadosty AT. Teaming beyond the clinical environment - building collective commitment across graduate medical education. BMC Med Educ 2023; 23:776. [PMID: 37853366 PMCID: PMC10585834 DOI: 10.1186/s12909-023-04713-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/21/2023] [Indexed: 10/20/2023]
Abstract
This commentary provides evidence and expert opinion on effective relationships and communication strategies for trainee and graduate medical education leaders. The authors also argue that consistent communication and alignment of goals between trainee leadership and graduate medical education leadership are essential components of a successful collaboration that promotes trainee well-being.
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Affiliation(s)
- Brady S Laughlin
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, 5881 E Mayo Blvd, Phoenix, AZ, USA.
| | - Elaine M Griffeth
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Aaron F Bush
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Cheryll A Albold
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Christopher J Boes
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Annie T Sadosty
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Laughlin BS, Corbin KS, Thorpe CS, Toesca DAS, Golafshar MA, McGee LA, Halyard M, Mutter RW, Keole SR, Park SS, Shumway D, Vallow LA, Vern-Gross TZ, Wong WW, DeWees TA, Vargas CE. Physician and Patient-Reported Outcomes of a Phase III Trial of Ultra-Hypofractionated vs. Moderate Hypofractionated Radiotherapy to the Whole Breast after Breast-Conserving Surgery. Int J Radiat Oncol Biol Phys 2023; 117:S6. [PMID: 37784534 DOI: 10.1016/j.ijrobp.2023.06.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) To report a final analysis evaluating physician and patient-reported outcomes of early breast cancer patients receiving moderate hypofractionation or ultra-hypofractionated whole breast radiotherapy (RT). MATERIALS/METHODS Between April 4, 2018, and February 11, 2020, patients with localized breast cancer (T1-T3, N0-N1, and M0) managed with breast-conserving surgery (BCS) were enrolled. Patients were randomized to receive whole breast RT with moderate hypofractionation to 40 Gy in 15 fractions (Arm A) or ultra-hypofractionation to 25 Gy in 5 fractions (Arm B). An optional concurrent integrated boost to 48 Gy on Arm A or 30 Gy on Arm B was allowed. Early toxicity (<3 months), late toxicity (> 3 months), quality of life (QOL), cosmesis, Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE), and deterioration of cosmesis were analyzed. RESULTS One hundred and seven patients were randomized to moderate hypofractionation (n = 54) or ultra-hypofractionation (n = 53). With a median follow-up of 36 months, no significant differences in patient characteristics were noted between the two arms. There were no patients with a grade ≥3 or higher toxicity. Grade 2 toxicities were 7.4% in Arm A and 7.5% in Arm B, and primarily consisted of radiation dermatitis (6 patients), fibrosis (1 patient) and lymphedema (1 patient). The average Harvard Cosmesis score and overall QoL were similar between arms at all time points, with no patients developing cosmetic deterioration. Patient-reported moderate to severe radiation skin burns were more commonly reported in Arm A (21.05%) vs. Arm B (6.25%) at the end of treatment (EOT) (p = 0.078). At EOT, patients receiving moderate hypofractionation had higher mean toxicity scores in breast tenderness (2.66 vs. 1.5, p = 0.018), skin flaking or peeling (0.63 vs. 0.06, p = 0.035), blistering (0.74 vs. 0.06, p = 0.028), pruritis (2.53 vs. 0.87, p < 0.001), erythema (4.24 vs. 2.0, p <0.001), telangiectasias (1.0 vs. 0.28, p = 0.021). Additionally, patients receiving moderate hypofractionation reported significantly worse changes from baseline at EOT in breast tenderness (-2.25 vs. -.86, p = 0.02), telangiectasia (-0.81 vs. 0.18, p = 0.012), skin discoloration (-4.31 vs. -1.04, p < 0.001), skin flaking or peeling (-.55 vs. 0.04, p = 0.053), blistering (-0.82 vs. -0.07, p = 0.033), and pruritus (-2.27 vs. -.67, p = 0.002). There was a return to baseline in all patient-reported breast domains by 3 months (p >0.05) in both arms. CONCLUSION Ultra-hypofractionated whole breast irradiation, consisting of 25 Gy in 5 fractions, provided comparable provider assessed toxicity and cosmetic outcomes to 40 Gy in 15 fractions. At the EOT assessment, ultra-hypofractionation had a better patient reported toxicity profile. Our findings provide further evidence to support daily ultra-hypofractionated whole breast radiotherapy as an appropriate treatment option for early-stage breast cancer.
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Affiliation(s)
- B S Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - K S Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - C S Thorpe
- Department of Radiation Oncology, Sanford Health, Fargo, ND
| | - D A S Toesca
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - M A Golafshar
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - L A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - M Halyard
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - R W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - S S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - D Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - L A Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - T Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - W W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - T A DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - C E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
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Laughlin BS, Zaniletti I, Vern-Gross T, Van Der Walt C, Allen-Rhoades W, Polites S, Rose PS, Ashman JB, Petersen IA, Haddock MG, Mahajan A, Keole SR, Laack NN, Ahmed SK. Clinical Outcomes for Chest Wall Ewing Sarcoma: A Multi-Center Single Institution Experience. Int J Radiat Oncol Biol Phys 2023; 117:e525. [PMID: 37785633 DOI: 10.1016/j.ijrobp.2023.06.1799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) We report tumor and treatment characteristics, oncologic outcomes, and treatment-associated toxicities in a cohort of chest wall Ewing sarcoma (cwES) patients treated at a single tertiary care institution. MATERIALS/METHODS After IRB approval, patients with cwES treated from 1997-2022 were retrospectively reviewed. Patient, tumor, treatment, outcomes, and toxicity data were abstracted. Local control (LC), progression-free survival (PFS), and overall survival (OS) were defined from end of treatment and assessed using the Kaplan-Meier method. Log-rank test and unadjusted Cox models were performed to determine factors associated with outcomes. RESULTS The cohort includes 45 patients. Median age at diagnosis was 19.8 years (range: 3.5 - 57.8 years). Five patients (11.1%) presented with pleural effusion and eight patients with lung metastases (17.8%). Two (4.4%) patients had metastatic disease outside the thorax. Median tumor volume (TV) was 138.6 mL (range: 3.0-6762.0 mL). All patients received VDC/IE chemotherapy. LC modality was surgery (S) in 21 patients (47%), radiation therapy (RT) in 5 (11%), and S+RT in 19 (42%). Median TV was larger in S+RT patients (319.4 mL, range: 5.3-6761.9 mL) compared to RT (152.3 mL, range: 20.4-366.9 mL) or S (70.4 mL, range: 3.1-1037.8 mL) (p = 0.03). R0 and R1 resections were performed in 36 (90%) and 4 (10%) patients, respectively. Proton beam therapy was used in 15 (63%) patients. Median dose was 50.40 Gy (range: 34.2 - 60 Gy) in 28 fractions to the primary tumor or post operative bed. Median dose for hemithorax (1 patient, 2.2%) and whole lung irradiation (7 patients, 15.6%) was 15.0 Gy (range: 15.0-15.0 Gy) in 10 fractions. Median follow-up was 2.38 years (range: 0 - 21.90 years). Five-year LC, PFS, and OS for all patients was 77.9% (95% CI, 65.3 - 92.9%), 54.2% (95% CI, 39.9 - 73.5%), and 63.5% (95% CI, 49.3 - 81.8%), respectively. In patients with localized disease, 5-year LC, PFS, and OS were 82.4% (95% CI, 67.9-99.8%), 66.4% (95% CI, 49.7-88.8%), and 71.3% (95% CI, 54.2-93.9%), respectively. Two-year LC by modality was 100% for RT (95% CI, 100-100%), 84.2% (95% CI, 69.3- 100%) for S and 73.3% (95% CI, 54 - 99.5%) for S+RT (p = 0.51). On univariate analysis, TV ≥ 200 mL was associated with a significantly worse 5-year OS (49.5%, TV ≥ 200 mL vs. 80.8%, TV < 200 mL; HR 4.44, p = 0.032) and PFS (35.2%, TV ≥ 200 mL vs. 76%, TV < 200 mL; HR 3.55, p = 0.025). TV ≥ 200 mL trended towards worse 5-year LC: 69.2% for TV ≥ 200 mL versus 81.5% for TV <200 mL [HR 2.26(95% CI 0.49 - 10.47), p = 0.287]. Overall, low rates of grade ≥2 toxicity were observed: 4 (8.9%) fatigue, 4 (8.9%) radiation dermatitis, 1 (2.2%) chyle leak, 3 (6.6%) scoliosis, 4 (8.9%) infection, 1 (2.2%) pneumonia, and 1 (2.2%) chest wall deformity. CONCLUSION RT is a safe, effective local therapy for small to moderate cwES tumors. Patients with TV ≥ 200 mL had significantly worse survival outcomes and an inferior LC rate. This suggests large cwES tumors may benefit from an aggressive multi-modality approach.
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Affiliation(s)
- B S Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - I Zaniletti
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - T Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - C Van Der Walt
- Department of Quantitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ
| | - W Allen-Rhoades
- Department of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, MN
| | - S Polites
- Department of Pediatric Surgery, Mayo Clinic, Rochester, MN
| | - P S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - J B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - I A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - M G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - A Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S R Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
| | - N N Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - S K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ
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11
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Garcia DA, Jeans EB, Morris LK, Shiraishi S, Laughlin BS, Rong Y, Rwigema JCM, Foote RL, Herman MG, Qian J. A Radiomics-Based Classifier for the Progression of Oropharyngeal Cancer Treated with Definitive Radiotherapy. Cancers (Basel) 2023; 15:3715. [PMID: 37509376 PMCID: PMC10377821 DOI: 10.3390/cancers15143715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
In this study, we investigated whether radiomics features from pre-treatment positron emission tomography (PET) images could be used to predict disease progression in patients with HPV-positive oropharyngeal cancer treated with definitive proton or x-ray radiotherapy. Machine learning models were built using a dataset from Mayo Clinic, Rochester, Minnesota (n = 72) and tested on a dataset from Mayo Clinic, Phoenix, Arizona (n = 22). A total of 71 clinical and radiomics features were considered. The Mann-Whitney U test was used to identify the top 2 clinical and top 20 radiomics features that were significantly different between progression and progression-free patients. Two dimensionality reduction methods were used to define two feature sets (manually filtered or machine-driven). A forward feature selection scheme was conducted on each feature set to build models of increased complexity (number of input features from 1 to 6) and evaluate model robustness and overfitting. The machine-driven features had superior performance and were less prone to overfitting compared to the manually filtered features. The four-variable Gaussian Naïve Bayes model using the 'Radiation Type' clinical feature and three machine-driven features achieved a training accuracy of 79% and testing accuracy of 77%. These results demonstrate that radiomics features can provide risk stratification beyond HPV-status to formulate individualized treatment and follow-up strategies.
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Affiliation(s)
- Darwin A Garcia
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Elizabeth B Jeans
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Lindsay K Morris
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Robert L Foote
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Jing Qian
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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12
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Duan J, Vargas CE, Yu NY, Laughlin BS, Toesca DS, Keole S, Rwigema JCM, Wong WW, Schild SE, Feng X, Chen Q, Rong Y. Incremental retraining, clinical implementation, and acceptance rate of deep learning auto-segmentation for male pelvis in a multiuser environment. Med Phys 2023. [PMID: 37287322 DOI: 10.1002/mp.16537] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/02/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Deep learning auto-segmentation (DLAS) models have been adopted in the clinic; however, they suffer from performance deterioration owing to the clinical practice variability. Some commercial DLAS software provide an incremental retraining function that enables users to train a custom model using their institutional data to account for clinical practice variability. PURPOSE This study was performed to evaluate and implement the commercial DLAS software with the incremental retraining function for definitive treatment of patients with prostate cancer in a multi-user environment. METHODS CT-based target organs and organs-at-risk (OAR) delineation of 215 prostate cancer patients were utilized. The performance of three commercial DLAS software built-in models was validated with 20 patients. A retrained custom model was developed using 100 patients and evaluated on the remaining data (n = 115). Dice similarity coefficient (DSC), Hausdorff distance (HD), mean surface distance (MSD), and surface DSC (SDSC) were utilized for quantitative evaluation. A multi-rater qualitative evaluation was blindly performed with a five-level scale. Visual inspection was performed in consensus and non-consensus unacceptable cases to identify the failure modes. RESULTS Three commercial DLAS vendor built-in models achieved sub-optimal performance in 20 patients. The retrained custom model had a mean DSC of 0.82 for prostate, 0.48 for seminal vesicles (SV), and 0.92 for rectum, respectively. This represents a significant improvement over the built-in model with DSC of 0.73, 0.37, and 0.81 for the corresponding structures. Compared to the acceptance rate of 96.5% and consensus unacceptable rate (i.e., both reviewers rated as unacceptable) of 3.5% achieved by manual contours, the custom model achieved a 91.3% acceptance rate and 8.7% consensus unacceptable rate. The failure modes of retrained custom model were attributed to the following: cystogram (n = 2), hip prosthesis (n = 2), low dose rate brachytherapy seeds (n = 2), air in endorectal balloon(n = 1), non-iodinated spacer (n = 2), and giant bladder(n = 1). CONCLUSION The commercial DLAS software with the incremental retraining function was validated and clinically adopted for prostate patients in a multi-user environment. AI-based auto-delineation of the prostate and OARs is shown to achieve improved physician acceptance, overall clinical utility, and accuracy.
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Affiliation(s)
- Jingwei Duan
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
- Department of Radiation Oncology, University of Kentucky, Lexington, Kentucky, USA
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Diego Santos Toesca
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Sameer Keole
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Xue Feng
- Carina Medical LLC, Lexington, Kentucky, USA
| | - Quan Chen
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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13
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Laughlin BS, Stoker J, Vern-Gross T. Proton Beam Therapy for Unresectable Mediastinal and Pericardial Spindle Cell Sarcoma: A Case Report. Int J Part Ther 2023; 10:43-50. [PMID: 37823013 PMCID: PMC10563663 DOI: 10.14338/ijpt-23-00001.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/29/2023] [Indexed: 10/13/2023] Open
Abstract
Unresectable mediastinal soft tissue sarcomas are often aggressive and associated with a poor prognosis. A 17-year-old male presented with progressive fatigue, shortness of breath, and heart palpitations secondary to an extensive mass involving the mediastinum and pericardium. He was treated with chemotherapy per protocol Children's Oncology Group Protocol ARST0332 and proton beam therapy to the involved mediastinum, pericardium, and heart. At the 5-year follow-up evaluation, he remained disease-free on surveillance imaging. An echocardiogram revealed a 55% to 60% left ventricular ejection fraction. Given the patient's extended survival, we present the oncologic rationale for treatment and considerations of late toxicity.
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Affiliation(s)
| | - Joshua Stoker
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Laughlin BS, Golafshar M, Prince M, Liu W, Kutyreff CJ, Ahmed SK, Vern Gross TZ, Haddock M, Petersen I, DeWees TA, Ashman JB. Dosimetric comparison between proton beam therapy, intensity modulated radiation therapy, and 3D conformal therapy for soft tissue extremity sarcoma. Acta Oncol 2023:1-7. [PMID: 37154167 DOI: 10.1080/0284186x.2023.2209267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
PURPOSE/OBJECTIVES Proton beam therapy (PBT) may provide a dosimetric advantage in sparing soft tissue and bone for selected patients with extremity soft sarcoma (eSTS). We compared PBT with photons plans generated using intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT). MATERIALS/METHODS Seventeen patients previously treated with pencil beam scanning PBT were included in this study. Of these patients, 14 treated with pre-operative 50 Gy in 25 fractions were analyzed. IMRT and 3D-CRT plans were created to compare against the original PBT plans. Dose-volume histogram (DVH) indices were evaluated amongst PBT, IMRT, and 3D plans. Kruskal-Wallis rank sum tests were used to get the statistical significance. A p value smaller than .05 was considered to be statistically significant. RESULTS For the clinical target volume (CTV), D2%, D95%, D98%, Dmin, Dmax, and V50Gy, were assessed. Dmin, D1%, Dmax, Dmean, V1Gy, V5Gy, and V50Gy were evaluated for the adjacent soft tissue. D1%, Dmax, Dmean, and V35-50% were evaluated for bone. All plans met CTV target coverage. The PBT plans delivered less dose to soft tissue and bone. The mean dose to the soft tissue was 2 Gy, 11 Gy, and 13 Gy for PBT, IMRT, and 3D, respectively (p < .001). The mean dose to adjacent bone was 15 Gy, 26 Gy, and 28 Gy for PBT, IMRT, and 3D, respectively (p = .022). CONCLUSION PBT plans for selected patients with eSTS demonstrated improved sparing of circumferential soft tissue and adjacent bone compared to IMRT and 3D-CRT. Further evaluation will determine if this improved dosimetry correlates with reduced toxicity and improved quality of life.
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Affiliation(s)
| | - Michael Golafshar
- Department of Quanitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | - Matthew Prince
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | - Michael Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Ivy Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Todd A DeWees
- Department of Quanitative Health Sciences, Section of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
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15
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Laughlin BS, Ebrahimi S, Voss MM, Patel SH, Foote RL, McGee LA, Garcia J, Ma DJ, Garces YI, Wittich MAN, Price KA, Schmitt A, Zhai Q, May BC, Nagel TH, Hinni ML, Chintakuntlawar AV, DeWees TA, Rwigema JCM. Clinicopathologic factors and their association with outcomes of salivary ductal carcinoma: a multi-center experience. Adv Radiat Oncol 2023; 8:101204. [PMID: 37152485 PMCID: PMC10157113 DOI: 10.1016/j.adro.2023.101204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Purpose This series reports long-term clinical outcomes of patients with salivary duct carcinoma (SDC), which is associated with a poor prognosis. Methods and Materials Eighty-nine patients with SDC were treated with curative intent from February 5, 1971, through September 15, 2018. Kaplan-Meier and competing risk analyses were used to estimate locoregional control, distant metastasis-free survival (DMFS), progression-free survival, and overall survival (OS). Cox regression analyses of disease and treatment characteristics were performed to discover predictors of locoregional control, DMFS, and OS. Results Median follow-up was 44.1 months (range, 0.23-356.67). The median age at diagnosis was 66 years (interquartile range, 57-75). Curative surgery followed by adjuvant radiation therapy was performed in 73 patients (82%). Chemotherapy was delivered in 26 patients (29.2%). The 5-year local recurrence and distant metastasis rates were 27% and 44%, respectively, with death as a competing risk. Distant metastasis was associated with lymph node-positive disease (hazard ratio [HR], 3.16; 95% confidence interval [CI], 1.38-7.23; P = .006), stage IV disease (HR, 4.78; 95% CI, 1.14-20.11; P = .033), perineural invasion (HR, 4.56; 95% CI, 1.74-11.97; P = .002), and positive margins (HR, 9.06; 95% CI, 3.88-21.14; P < .001). Median OS was 4.84 years (95% CI, 3.54-7.02). The 5-year OS was 42%. Reduced OS was associated with lymphovascular space invasion (HR, 3.49; 95% CI, 1.2-10.1; P = .022), perineural invasion (HR, 2.05; 95% CI, 1.06-3.97; P = .033), positive margins (HR, 2.7; 95% CI, 1.3-5.6; P = .011), N2 disease (HR, 1.88; 95% CI, 1.03-3.43; P = .04), and N3 disease (HR, 11.76; 95% CI, 3.19-43.3; P < .001). Conclusions In this single-institution, multicenter retrospective study, the 5-year survival was 42% in patients with SDC. Lymphovascular space invasion, lymph node involvement, and higher staging at diagnosis were associated with lower DMFS and OS.
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16
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Thorpe CS, DeWees TA, Laughlin BS, Vallow LA, Seneviratne D, Pockaj BA, Cronin PA, Halyard MY, Vern-Gross TZ, McGee LA, McLaughlin SA, Voss MM, Golafshar MA, Bulman GF, Vargas CE. Pilot/Phase II Trial of Hypofractionated Radiation Therapy to the Whole Breast Alone Before Breast Conserving Surgery. Adv Radiat Oncol 2023; 8:101111. [PMID: 36483068 PMCID: PMC9723298 DOI: 10.1016/j.adro.2022.101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose Our purpose was to report the results of a phase II trial of patients with breast cancer treated with hypofractionated whole breast radiation therapy (RT) before breast-conserving surgery (BCS). Methods and materials Between 2019 and 2020, patients with cT0-T2, N0, M0 breast cancer were enrolled. Patients were treated with hypofractionated whole breast RT, 25 Gy in 5 fractions, 4 to 8 weeks before BCS. Pathologic assessment was performed using the residual cancer burden (RCB). Toxicities were assessed according to Common Terminology Criteria for Adverse Events (version 4). Quality of life was assessed with Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, The Breast Cancer Treatment Outcome Scale, Linear Analogue Self-Assessment, and Patient-Reported Outcomes Measurement Information System. Results Twenty-two patients were enrolled. Median follow-up was 7.6 months (range, 0.2-16.8). Seven (32%) and 2 (9%) patients experienced grade 2+ or 3 toxicities, respectively. Overall quality of life Linear Analogue Self-Assessment and Patient-Reported Outcomes Measurement Information System did not change significantly from baseline (P = .21 and P = .72, respectively). There was no clinically significant change (≥1 point) in any of The Breast Cancer Treatment Outcome Scale domains. Only 1 (5%) patient experienced a clinical deterioration that corresponded to a "fair" outcome on the Harvard Cosmesis Scale. At pathologic evaluation, 14 (64%) patients had RCB-0 or RCB-I, including 3 (14%) patients with a pathologic complete response (RCB-0). Eight patients (36%) had RCB-II. No local or distant recurrences have been observed. Conclusions Extremely hypofractionated whole breast RT before BCS is a feasible approach. There were low rates of toxicities and good cosmesis. Further investigation into this approach with RT before BCS is warranted.
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Affiliation(s)
| | - Todd A. DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
| | | | - Laura A. Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Dee Seneviratne
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | | | | | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Molly M. Voss
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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17
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Laughlin BS, Yu NY, Lo S, Duan J, Welchel Z, Tinnon K, Beckett M, Schild SE, Wong WW, Keole SR, Rwigema JCM, Vargas CE, Rong Y. Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy-Part 2: Feasibility of Margin Reduction for Fractionated Radiation Treatment with Advanced Image Guidance. Cancers (Basel) 2022; 15:cancers15010040. [PMID: 36612040 PMCID: PMC9817842 DOI: 10.3390/cancers15010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/08/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: Planning target volume (PTV) expansion for post-prostatectomy radiotherapy is typically ≥5 mm. Recent clinical trials have proved the feasibility of a reduced margin of 2−3 mm for treatments on MRI-linac. We aim to study the minimum PTV margin needed using iterative cone-beam CT (iCBCT) as image guidance on conventional linacs. Materials/Methods: Fourteen patients who received post-prostatectomy irradiation (8 with an endorectal balloon and 6 without a balloon) were included in this study. Treatment was delivered with volumetric modulated radiation therapy (VMAT). Fractional dose delivery was evaluated in 165 treatment fractions. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. PTV margins (0 mm, 2 mm, and 4 mm) were evaluated on daily iCBCT. CTV coverage and OAR dose parameters were assessed with each PTV margin. Results: CTV D100% was underdosed with a 0 mm margin in 32% of fractions in comparison with 2 mm (6%) and 4 mm (6%) PTV margin (p ≤ 0.001). CTV D95% > 95% was met in 93−94% fractions for all PTV expansions. CTV D95% > 95% was achieved in more patients with an endorectal balloon than those without: 0 mm—90/91 (99%) vs. 63/74 (85%); 2 mm—90/91 (99%) vs. 65/75 (87%); 4 mm—90/90 (100%) vs. 63/73 (86%). There was no difference in absolute median change in CTV D95% (0.32%) for 0-, 2-, and 4 mm margins. The maximum dose remained under 108% for 100% (0 mm), 97% (2 mm), and 98% (4 mm) of images. Rectal wall maximum dose remained under 108% for 100% (0 mm), 100% (2 mm), and 98% (4 mm) of images. Conclusions: With high-quality iCBCT image guidance, PTV margin accounting for inter-fractional uncertainties can be safely reduced for post-prostatectomy radiotherapy. For fractionated radiotherapy, an isotropic expansion of 2 mm and 4 mm may be considered for margin expansion with and without the endorectal balloon. Future application for margin reduction needs to be further evaluated and considered with the advent of shorter post-prostatectomy radiation courses.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Nathan Y. Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Stephanie Lo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Jingwei Duan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Radiation Oncology, University of Kentucky, Lexington, KY 40506, USA
| | - Zachary Welchel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Department of Nuclear and Radiological Engineering, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - Katie Tinnon
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Mason Beckett
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
| | | | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ 85259, USA
- Correspondence: (C.E.V.); (Y.R.)
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Laughlin BS, Lo S, Vargas CE, DeWees TA, Van der Walt C, Tinnon K, Beckett M, Hobbis D, Schild SE, Wong WW, Keole SR, Rwigema JCM, Yu NY, Clouser E, Rong Y. Clinical Practice Evolvement for Post-Operative Prostate Cancer Radiotherapy-Part 1: Consistent Organs at Risk Management with Advanced Image Guidance. Cancers (Basel) 2022; 15:cancers15010016. [PMID: 36612013 PMCID: PMC9817677 DOI: 10.3390/cancers15010016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/07/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: Post-operative prostate cancer patients are treated with full bladder instruction and the use of an endorectal balloon (ERB). We reassessed the efficacy of this practice based on daily image guidance and dose delivery using high-quality iterative reconstructed cone-beam CT (iCBCT). Methods: Fractional dose delivery was calculated on daily iCBCT for 314 fractions from 14 post-operative prostate patients (8 with and 6 without ERB) treated with volumetric modulated radiotherapy (VMAT). All patients were positioned using novel iCBCT during image guidance. The bladder, rectal wall, femoral heads, and prostate bed clinical tumor volume (CTV) were contoured and verified on daily iCBCT. The dose-volume parameters of the contoured organs at risk (OAR) and CTV coverage were assessed for the clinical impact of daily bladder volume variations and the use of ERB. Minimum bladder volume was studied, and a straightforward bladder instruction was explored for easy clinical adoption. Results: A “minimum bladder” contour, the overlap between the original bladder contour and a 15 mm anterior and superior expansion from prostate bed PTV, was confirmed to be effective in identifying cases that might fail a bladder constraint of V65% <60%. The average difference between the maximum and minimum bladder volumes for each patient was 277.1 mL. The daily bladder volumes varied from 62.4 to 590.7 mL and ranged from 29 to 286% of the corresponding planning bladder volume. The bladder constraint of V65% <60% was met in almost all fractions (98%). CTVs (D90%, D95%, and D98%) remained well-covered regardless of the absolute bladder volume daily variation or the presence of the endorectal balloon. Patients with an endorectal balloon showed smaller variation but a higher average maximum rectal wall dose (D0.03mL: 104.3% of the prescription) compared to patients without (103.3%). Conclusions: A “minimum bladder” contour was determined that can be easily generated and followed to ensure sufficient bladder sparing. Further analysis and validation are needed to confirm the utility of the minimal bladder contour. Accurate dose delivery can be achieved for prostate bed target coverage and OAR sparing with or without the use of ERB.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Stephanie Lo
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Todd A. DeWees
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Charles Van der Walt
- Department of Qualitative Health Sciences, Section of Biostatistics, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Katie Tinnon
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Mason Beckett
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Jean-Claude M. Rwigema
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Nathan Y. Yu
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Edward Clouser
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic, 5881 E Mayo Blvd., Phoenix, AZ 85054, USA
- Correspondence:
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19
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Laughlin BS, Voss MM, Toesca DA, Daniels T, Golafshar MA, Keole SR, Wong WW, Rwigema JC, Davis B, Schild SE, Stish BJ, Choo R, Lester S, DeWees TA, Vargas CE. Preliminary Analysis of a Phase II Trial of Stereotactic Body Radiation Therapy for Prostate Cancer With High-Risk Features After Radical Prostatectomy. Adv Radiat Oncol 2022; 8:101143. [PMID: 36845611 PMCID: PMC9943785 DOI: 10.1016/j.adro.2022.101143] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose There are limited data regarding using stereotactic body radiation therapy (SBRT) in the postprostatectomy setting. Here, we present a preliminary analysis of a prospective phase II trial that aimed to evaluate the safety and efficacy of postprostatectomy SBRT for adjuvant or early salvage therapy. Materials and Methods Between May 2018 and May 2020, 41 patients fulfilled inclusion criteria and were stratified into 3 groups: group I (adjuvant), prostate-specific antigen (PSA) < 0.2 ng/mL with high-risk features including positive surgical margins, seminal vesicle invasion, or extracapsular extension; group II (salvage), with PSA ≥ 0.2 ng/mL but < 2 ng/mL; or group III (oligometastatic), with PSA ≥ 0.2 ng/mL but < 2 ng/mL and up to 3 sites of nodal or bone metastases. Androgen deprivation therapy was not offered to group I. Androgen deprivation therapy was offered for 6 months for group II and 18 months for group III patients. SBRT dose to the prostate bed was 30 to 32 Gy in 5 fractions. Baseline-adjusted physician reported toxicities (Common Terminology Criteria for Adverse Events), patient reported quality-of-life (Expanded Prostate Index Composite, Patient-Reported Outcome Measurement Information System), and American Urologic Association scores were evaluated for all patients. Results The median follow-up was 23 months (range, 10-37). SBRT was adjuvant in 8 (20%) patients, salvage in 28 (68%), and salvage with the presence of oligometastases in 5 (12%) patients. Urinary, bowel, and sexual quality of life domains remained high after SBRT. Patients tolerated SBRT with no grade 3 or higher (3+) gastrointestinal or genitourinary toxicities. The baseline adjusted acute and late toxicity grade 2 genitourinary (urinary incontinence) rate was 2.4% (1/41) and 12.2% (5/41). At 2 years, clinical disease control was 95%, and biochemical control was 73%. Among the 2 clinical failures, 1 was a regional node and the other a bone metastasis. Oligometastatic sites were salvaged successfully with SBRT. There were no in-target failures. Conclusions Postprostatectomy SBRT was very well tolerated in this prospective cohort, with no significant effect on quality of life metrics postirradiation, while providing excellent clinical disease control.
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Affiliation(s)
| | - Molly M. Voss
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
| | | | - Thomas Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona,Department of Radiation Oncology, NYU Langone Health, Brooklyn, New York
| | | | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Brian Davis
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Brad J. Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Richard Choo
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Scott Lester
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Todd A. DeWees
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona
| | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona,Corresponding author: Carlos E. Vargas, MD
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20
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Laughlin BS, Bhangoo RS, Niska JR, Thorpe CS, Girardo ME, Anderson JD, Kosiorek HE, McGee LA, Hartsell WF, Chang JH, Rossi CJ, Tsai HK, Choi IJ, Vargas CE. Proton therapy for isolated local regional recurrence of breast cancer after mastectomy alone. Front Oncol 2022; 12:925078. [DOI: 10.3389/fonc.2022.925078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose/ObjectivesTo assess adverse events (AEs) and disease-specific outcomes after proton therapy for isolated local-regional recurrence (LRR) of breast cancer after mastectomy without prior radiotherapy (RT).Materials/MethodsPatients were identified from a multi-institutional prospective registry and included if diagnosed with invasive breast cancer, initially underwent mastectomy without adjuvant RT, experienced an LRR, and subsequently underwent salvage treatment, including proton therapy. Follow-up and cancer outcomes were measured from the date of RT completion.ResultsNineteen patients were included. Seventeen patients were treated with proton therapy to the chest wall and comprehensive regional lymphatics (17/19, 90%). Maximum grade AE was grade 2 in 13 (69%) patients and grade 3 in 4 (21%) patients. All patients with grade 3 AE received > 60 GyE (p=0.04, Spearman correlation coefficient=0.5). At the last follow-up, 90% of patients were alive with no LRR or distant recurrence.ConclusionsFor breast cancer patients with isolated LRR after initial mastectomy without adjuvant RT, proton therapy is well-tolerated in the salvage setting with excellent loco-regional control. All grade 3 AEs occurred in patients receiving > 60 GyE.
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21
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Anderson JD, Voss MM, Laughlin BS, Garda AE, Aziz K, Mullikin TC, Haddock MG, Petersen IA, DeWees TA, Vora SA. Outcomes of Proton Beam Therapy Compared With Intensity-Modulated Radiation Therapy for Uterine Cancer. Int J Part Ther 2022; 9:10-17. [PMID: 36721479 PMCID: PMC9875825 DOI: 10.14338/ijpt-22-00020.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose To compare Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) in patients with endometrial cancer receiving adjuvant pelvic radiation therapy with proton beam therapy (PT) versus intensity-modulated radiation therapy (IMRT). Materials and Methods Patients with uterine cancer treated with curative intent who received either adjuvant PT or IMRT between 2014 and 2020 were identified. Patients were enrolled into a prospective registry using a gynecologic-specific subset of PRO-CTCAE designed to assess symptom impact on daily living. Questions included gastrointestinal (GI) symptoms of diarrhea, flatulence, bowel incontinence, and constipation in addition to other pertinent gynecologic, urinary, and other general symptoms. Symptom-based questions were on a 0- to 4-point scale, with grade 3+ symptoms occurring frequently or almost always. Patient-reported toxicity was analyzed at baseline, end of treatment (EOT), and at 3, 6, 9, and 12 months after treatment. Unequal variance t tests were used to determine if treatment type was a significant factor in baseline-adjusted PRO-CTCAE. Results Sixty-seven patients met inclusion criteria. Twenty-two received PT and 45 patients received IMRT. Brachytherapy boost was delivered in 73% of patients. Median external beam dose was 45 Gy for both PT and IMRT (range, 45-58.8 Gy). When comparing PRO-CTCAE, PT was associated with less diarrhea at EOT (P = .01) and at 12 months (P = .24) than IMRT. Loss of bowel control at 12 months was more common in patients receiving IMRT (P = .15). Any patient reporting grade 3+ GI toxicity was noted more frequently with IMRT (31% versus 9%, P = .09). Discussion Adjuvant PT is a promising treatment for patients with uterine cancer and may reduce patient-reported GI toxicity as compared with IMRT.
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Affiliation(s)
| | - Molly M. Voss
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Allison E. Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Khaled Aziz
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Trey C. Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Ivy A. Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Todd A. DeWees
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, AZ, USA
| | - Sujay A. Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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22
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Laughlin BS, Bhangoo RS, Thorpe CS, Golafshar MA, DeWees TA, Anderson JD, Vern-Gross TZ, McGee LA, Wong WW, Halyard MY, Keole SR, Vargas CE. Patient-reported outcomes for patients with breast cancer undergoing radiotherapy: A single-center registry experience. Front Oncol 2022; 12:920739. [PMID: 36091145 PMCID: PMC9458857 DOI: 10.3389/fonc.2022.920739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background We present Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE) for patients undergoing adjuvant radiotherapy for breast cancer with curative intent. We describe the frequency and severity of PRO-CTCAE and analyze them with respect to dose fractionation. Methods Patients were included in this study if they were treated with curative intent for breast cancer and enrolled on a prospective registry. Patients must have completed at least one baseline and one post-radiation survey that addressed PRO-CTCAE. For univariate and multivariate analysis, categorical variables were analyzed by Fisher’s exact test and continuous variables by Wilcoxon rank sum test. PRO-CTCAE items graded ≥2 and ≥3 were analyzed between patients who received hypofractionation (HF) versus standard conventional fractionation (CF) therapy by the Chi-square test. Results Three hundred thirty-one patients met inclusion criteria. Pathologic tumor stage was T1–T2 in 309 (94%) patients. Eighty-seven (29%) patients were node positive. Two hundred forty-seven patients (75%) experienced any PRO-CTCAE grade ≥2, and 92 (28%) patients experienced any PRO-CTCAE grade ≥3. CF was found to be associated with an increased risk of grade ≥3 skin toxicity, swallowing, and nausea (all p < 0.01). HF (OR 0.48, p < 0.01) was significant in the multivariate model for decreased risk of any occurrence of PRO-CTCAE ≥3. Conclusions Our study reports one of the first clinical experiences utilizing multiple PRO-CTCAE items for patients with breast cancer undergoing radiation therapy with curative intent. Compared with CF, HF was associated with a significant decrease in any PRO-CTCAE ≥3 after multivariate analysis.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Ronik S. Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Cameron S. Thorpe
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Michael A. Golafshar
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Todd A. DeWees
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ, United States
| | - Justin D. Anderson
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | | | - Lisa A. McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Michele Y. Halyard
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Carlos E. Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
- *Correspondence: Carlos E. Vargas,
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23
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Laughlin BS, Silva AC, Vora SA, Keole SR, Wong WW, Schild MH, Schild SE. Long-term outcomes of prostate intensity-modulated radiation therapy incorporating a simultaneous intra-prostatic MRI-directed boost. Front Oncol 2022; 12:921465. [PMID: 36033460 PMCID: PMC9399820 DOI: 10.3389/fonc.2022.921465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 07/18/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose/objectives This retrospective study demonstrates the long-term outcomes of treating prostate cancer using intensity modulated (IMRT) with incorporation of MRI-directed boost. Materials/methods From February 2009 to February 2013, 78 men received image-guided IMRT delivering 77.4 Gy in 44 fractions with simultaneously integrated boost to 81–83 Gy to an MRI-identified lesion. Patients with intermediate-risk or high-risk prostate cancer were recommended to receive 6 and 24–36 months of adjuvant hormonal therapy, respectively. Results Median follow-up was 113 months (11–147). There were 18 low-risk, 43 intermediate-risk, and 17 high-risk patients per NCCN risk stratification included in this study. Adjuvant hormonal therapy was utilized in 32 patients (41%). The 10-year biochemical control rate for all patients was 77%. The 10-year biochemical control rates for low-risk, intermediate-risk, and high-risk diseases were 94%, 81%, and 88%, respectively (p = 0.35). The 10-year rates of local control, distant control, and survival were 99%, 88%, and 66%, respectively. Of 25 patients who died, only four (5%) died of prostate cancer. On univariate analysis, T-category and pretreatment PSA level were associated with distant failure rate (p = 0.02). There was no grade =3 genitourinary and gastrointestinal toxicities that persisted at the last follow-up. Conclusions This study demonstrated the long-term efficacy of using MRI to define an intra-prostatic lesion for SIB to 81–83Gy while treating the entire prostate gland to 77.4 Gy with IMRT. Our study confirms that modern MRI can be used to locally intensify dose to prostate tumors providing high long-term disease control while maintaining favorable long-term toxicity.
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Affiliation(s)
- Brady S. Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Alvin C. Silva
- Department of Radiology, Mayo Clinic, Phoenix, AZ, United States
| | - Sujay A. Vora
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - Sameer R. Keole
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | - William W. Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
| | | | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, United States
- *Correspondence: Steven E. Schild,
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24
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Laughlin BS, Golafshar MA, Lin K, Goulding K, Roesler K, Vern-Gross T, Seetharam M, Zaniletti I, Ashman JB. Long-term experience with intraoperative electron radiation therapy boost in extremity sarcoma. J Surg Oncol 2022; 126:1279-1287. [PMID: 35856506 DOI: 10.1002/jso.27024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/17/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND In patients with extremity soft tissue sarcoma (eSTS), we describe outcomes of preoperative external beam radiation therapy (EBRT), limb-sparing surgery (LSS), and intraoperative electron radiation therapy (IOERT). METHODS One hundred and eighteen patients with eSTS treated between October 17, 2002 and July 28, 2021 were identified. EBRT was delivered preoperatively followed by LSS and IOERT. RESULTS The median follow-up was 24.9 months. The presentation was primary in 102 (94%) patients and recurrent in 6 (6%) patients. Tumor location was lower extremity in 82 (76%) patients and upper extremity in 26 (24%) patients. Stage distribution was as follows: 3 (3%) IA, 24 (22%) IB, 31 (29%) II, 24 (22%) IIIA, and 25 (23%) IIIB. Final surgical margins were negative in 96 (89%) patients. The 5-year local control, failure-free survival, and overall survival were 94%, 75%, and 64%, respectively. Univariate analysis identified age >50, lower extremity, and higher grade as significant negative prognostic factors for overall survival. Grade 3 fracture or osteoradionecrosis requiring surgical fixation, neuropathy, and lymphedema occurred in 7 (6%), 1 (1%), and 0 patients, respectively. CONCLUSIONS This study represents one of the largest series using preoperative EBRT, LSS, and IOERT for eSTS, with high local control and a low rate of late severe toxicity.
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Affiliation(s)
- Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Michael A Golafshar
- Department of Qualitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Keldon Lin
- Mayo Clinic Alix School of Medicine, Scottsdale, Arizona, USA
| | - Krista Goulding
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Tamara Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Mahesh Seetharam
- Department of Hematology and Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Isabella Zaniletti
- Department of Qualitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jonathan B Ashman
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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25
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Laughlin BS, Narang GL, Cheney SM, Humphreys MR, Vargas CE, Keole SR, Rwigema JM, Schild SE, Wong WW. Toxicity and outcomes after external beam irradiation for prostate cancer in patients with prior holmium laser enucleation of the prostate: Early experience. Cancer Rep (Hoboken) 2022; 6:e1672. [PMID: 35790091 PMCID: PMC9875616 DOI: 10.1002/cnr2.1672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/11/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
PURPOSE/OBJECTIVES Holmium laser enucleation of the prostate (HoLEP) is commonly performed in patients with significant bladder outlet obstruction. However, there are few reports on the toxicity of external beam irradiation (RT) for prostate cancer in patients after prior HoLEP. In this study, we evaluate the side effects and treatment outcomes of RT after HoLEP. MATERIALS/METHODS Eighteen patients who had HoLEP and subsequently received RT for prostate cancer were included. Data collected included patient and disease characteristics, urinary function, and radiation dose. Acute and late urinary (GU) and gastrointestinal (GI) side effects were evaluated. Disease control and survival rates were calculated using Kaplan-Meier method. RESULTS Median follow-up was 18 months (range: 4-46 months). Median prostate volume was 107 ml before HoLEP and 24 ml after HoLEP. Median International Prostate Symptom Score (IPSS) was 17 (range: 5-32) before HoLEP. Median decline in IPSS score after HoLEP was 7 (range: -2-21). On uroflow study, peak flow rate, and post-void residual were significantly improved after HoLEP. After radiation, peak flow rate and average flow rate showed a decline but remained significantly improved compared to pre-HoLEP measurements. Maximum acute Common Terminology Criteria for Adverse Events (CTCAE) adverse events were 12 grade 1 and 3 grade 2 for GU, and 3 grade 1 for GI, respectively. Maximum late adverse events were 13 grade 1 and 2 grade 2 for GU, and all grade 0 for GI, respectively. At last follow-up, there were 8 grade 1 and 1 grade 2 late GU, and 3 grade 1 late GI adverse events, respectively. There was no significant increase in urinary incontinence after RT compared to before RT. The 18-month biochemical control, local control, distant control rates were 78%, 94%, and 80%, respectively. CONCLUSIONS Patients who received RT as definitive treatment for prostate cancer after prior HoLEP had low risk of serious acute and late side effects. HoLEP can be safely performed and should be considered in patients with significant bladder outlet obstruction and large prostate volume before RT.
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Affiliation(s)
| | | | | | | | | | | | | | | | - William W. Wong
- Department of Radiation Oncology, Mayo ClinicPhoenixArizonaUSA
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26
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Laughlin BS, Golafshar MA, Ahmed S, Prince M, Anderson JD, Vern-Gross T, Seetharam M, Goulding K, Petersen I, DeWees T, Ashman JB. Early Experience Using Proton Beam Therapy for Extremity Soft Tissue Sarcoma: A Multicenter Study. Int J Part Ther 2022; 9:1-11. [PMID: 35774491 PMCID: PMC9238125 DOI: 10.14338/ijpt-21-00037.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Abstract
Purpose
Proton beam therapy (PBT) may provide an advantage when planning well-selected patients with extremity soft tissue sarcoma (eSTS), specifically for large, anatomically challenging cases. We analyzed our early experience with PBT on toxicity and outcomes.
Materials and Methods
A retrospective study was performed for eSTS treated between June 2016 and October 2020 with pencil beam scanning PBT at 2 institutions. Diagnostic, treatment, and toxicity characteristics were gathered from baseline to last follow-up or death. Wound complications were defined as secondary operations for wound repair (debridement, drainage, skin graft, and muscle flap) or nonoperative management requiring hospitalization. Statistical analysis was performed with R software.
Results
Twenty consecutive patients with a median age 51.5 years (range, 19–78 years) were included. Median follow-up was 13.7 months (range, 1.7–48.1 months). Tumor presentation was primary (n = 17) or recurrent after prior combined modality therapy (n = 3). Tumor location was either lower extremity (n = 16) or upper extremity (n = 4). Radiation was delivered preoperatively in most patients (n = 18). Median pretreatment tumor size was 7.9 cm (range, 1.3 –30.0 cm). The 1-year locoregional control was 100%. Four patients (20%) had developed metastatic disease by end of follow-up. Maximum toxicity for acute dermatitis was grade 2 in 8 patients (40%) and grade 3 in 3 patients (15%). After preoperative radiation and surgical resection, acute wound complications occurred in 6 patients (35%). Tumor size was larger in patients with acute wound complications compared with those without (medians 16 cm, range [12–30.0 cm] vs 6.3 cm, [1.3–14.4 cm], P = .003).
Conclusion
PBT for well selected eSTS cases demonstrated excellent local control and similar acute wound complication rate comparable to historic controls. Long-term follow-up and further dosimetric analyses will provide further insight into potential advantages of PBT in this patient population.
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Affiliation(s)
| | | | - Safia Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Matthew Prince
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | | | | | - Mahesh Seetharam
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Krista Goulding
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Ivy Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Todd DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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27
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Laughlin BS, Anderson JD, Gagneur JD, Chungbin SJ, Bues M, Hobbis D, Fatyga M, Korte SM, Carroll SE, Vora S, Sio TT, Wong WW, Keole SR, Rong Y. Implementation of Photon Treatment Back-Up Workflow at a High-Volume Proton Center: Safety, Quality, and Patient Considerations. Pract Radiat Oncol 2022; 12:e453-e459. [PMID: 35272078 DOI: 10.1016/j.prro.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 11/30/2022]
Abstract
A successful proton beam therapy (PBT) center relies heavily on the proper function and maintenance of a proton beam therapy machine. However, when a PBT machine is non-operational, a proton facility is hindered with delays that can potentially lead to inferior treatment outcome due to treatment interruption. The implementation of a workflow for which proton plans are converted to photon plans so that patients can be treated using photon has been a successful strategy to reduce delays and mitigate its impact on patient care. This workflow was established through collaboration of physicians, physicists, dosimetrists, therapists, nurses, and schedulers. A tiered system established by disease site, number of fractions, and individualized circumstances is used to prioritize patients. This article provides an overview of workflow of conversion of PBT to photon when the PBT machine is down. Specific needs of patients undergoing proton beam therapy are addressed.
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Affiliation(s)
- Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Justin D Anderson
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Justin D Gagneur
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Suzanne J Chungbin
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Shawn M Korte
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Sarah E Carroll
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Sujay Vora
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, 5881 E Mayo Boulevard, Phoenix, Arizona, 85054.
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Laughlin BS, Petersen MM, Yu NY, Anderson JD, Rule WG, Borad MJ, Aqel BA, Sonbol MB, Mathur AK, Moss AA, Bekaii-Saab TS, Ahn DH, DeWees TA, Sio TT, Ashman JB. Clinical outcomes for hilar and extrahepatic cholangiocarcinoma with adjuvant, definitive, or liver transplant-based neoadjuvant chemoradiotherapy strategies: a single-center experience. J Gastrointest Oncol 2022; 13:288-297. [PMID: 35284111 PMCID: PMC8899753 DOI: 10.21037/jgo-21-615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/11/2022] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND We report our experience with 3 strategies for treating hilar and extrahepatic cholangiocarcinoma (CCA) including chemoradiotherapy: neoadjuvant chemoradiotherapy (nCRT) and orthotopic liver transplant, surgical resection and adjuvant chemoradiotherapy (aCRT), and definitive chemoradiotherapy (dCRT). METHODS We included patients treated from 1998 through 2019. Kaplan-Meier estimates, log-rank testing, and univariate/multivariate Cox models were used to assess outcomes (local progression-free survival, disease-free survival, and overall survival). RESULTS Sixty-five patients (nCRT, n=20; aCRT, n=16; dCRT, n=29) met inclusion criteria [median (range) age 65 years (27-84 years)]. Median posttreatment follow-up was 19.1 months (0.8-164.8 months) for all patients and 38.6, 24.3, and 9.0 months for the nCRT, aCRT, and dCRT groups, respectively. At 3 and 5 years, overall survival was 78% and 59% for the nCRT group; 47% and 35%, aCRT group; and 11% and 0%, dCRT group. Compared with the dCRT group, the nCRT group (hazard ratio =0.13, 95% CI: 0.05-0.33) and the aCRT group (hazard ratio =0.29, 95% CI: 0.14-0.64) had significantly improved overall survival (P<0.001). The 5-year local progression-free survival (50% nCRT vs. 30% aCRT vs. 0% dCRT, P<0.001) and 5-year disease-free survival (61% nCRT vs. 30% aCRT vs. 0% dCRT, P=0.01) were significantly better for strategies combined with surgery. CONCLUSIONS Outcomes for patients with extrahepatic CCA were superior for those who underwent nCRT/orthotopic liver transplant or postsurgical aCRT than for patients treated with dCRT. The excellent outcomes after nCRT/orthotopic liver transplant provide additional independent data supporting the validity of this strategy. The poor survival of patients treated with dCRT highlights a need for better therapies when surgery is not possible.
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Affiliation(s)
- Brady S. Laughlin
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - Molly M. Petersen
- Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Arizona, USA
| | - Nathan Y. Yu
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - Justin D. Anderson
- Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - William G. Rule
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mitesh J. Borad
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Bashar A. Aqel
- Division of Gastroenterology and Hepatology, Mayo Clinic Hospital, Phoenix, Arizona, USA
- Transplant Center, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Mohamad B. Sonbol
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Amit K. Mathur
- Transplant Center, Mayo Clinic Hospital, Phoenix, Arizona, USA
- Division of Transplant and Hepatobiliary Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Adyr A. Moss
- Transplant Center, Mayo Clinic Hospital, Phoenix, Arizona, USA
- Division of Transplant and Hepatobiliary Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Tanios S. Bekaii-Saab
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Daniel H. Ahn
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
- Mayo Clinic Cancer Center, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Todd A. DeWees
- Clinical Trials and Biostatistics, Mayo Clinic, Scottsdale, Arizona, USA
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Terence T. Sio
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Jonathan B. Ashman
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
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Laughlin BS, Ashman JB, Rule WG, Yu NY, Sio TT. Excellent clinical outcomes can be achieved with neoadjuvant chemoradiation and orthotopic liver transplantation for unresectable cholangiocarcinoma: support for the need of an international transplant protocol. J Gastrointest Oncol 2022; 13:2699-2700. [DOI: 10.21037/jgo-2022-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/11/2022] [Indexed: 11/06/2022] Open
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Laughlin BS, Petersen MM, Ashman JB, Rule WG, Borad MJ, Aqel BA, Sonbol MB, Bekaii-Saab TS, Ahn DH, Yu NY, DeWees T, Sio TTW. Clinical outcome associated with neoadjuvant chemoradiation and orthotopic liver transplantation versus definitive chemoradiation in 49 patients with unresectable, hilar, or extrahepatic cholangiocarcinoma. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.4_suppl.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
494 Background: Our aim was to compare survival between patients receiving neoadjuvant chemoradiation and orthotopic liver transplantation (OLT group) versus definitive chemoradiation (CRT group) for extrahepatic or hilar cholangiocarcinoma. Methods: 49 patients (20 in OLT group vs. 29 in CRT group) with unresectable hilar/extrahepatic cholangiocarcinoma were treated at Mayo Clinic Arizona between Feb. 1998–Sep. 2019. Treatment included external beam radiation therapy (median 4500cGy) and boost (median 900cGy) with either continuous 5-flurouracil (dose range 180–225 mg/m2) or capecitabine (dose range 825–1000 mg/m2 BID) prior to or without OLT. Radiation boosts were delivered with EBRT or bile duct brachytherapy. Patients were between 27.9–84.3 years (median 64.3) at diagnosis. 18 patients had previous diagnosis of PSC. Results: Between Feb. 1998–Sep. 2019, 31(63%) of 49 patients died by the end of follow-up. Of patients treated with neoadjuvant therapy and OLT, 7(35%) of 20 patients died. 24(86%) of 28 patients treated with definitive therapy died. The OLT cohort were younger (mean age 56.5 vs. 69.0 years), more likely to have PSC and UC (65% vs. 17%), and had a lower CA 19-9 (median 43 vs. 535)(P < 0.003). From the end date of radiation, median overall survival was 76.8 months vs. 15.6 months for the OLT and CRT groups, respectively. Survival rates at 3 and 5 years were 78% and 69% in the OLT group compared to 19% and 6% in the CRT group (HR 7.73; 3.04-19.65:(P < 0.0001)). Progression-free survival (89% vs. 30% at 3 years), and distant metastasis-free survival (88% vs. 66% at 3 years) favored OLT versus CRT alone (HR 5.74;1.12-29.34:(P < 0.02)). Univariate analysis demonstrated that the method of treatment (OLT vs. CRT) was the only variable associated with better clinical outcomes. Conclusions: In patients with unresectable extrahepatic/hilar cholangiocarcinoma, survival was higher in those who underwent chemoradiation and OLT. Patients who received definitive chemoradiation in the absence of OLT were expected to have worse overall, progression-free, and metastasis-free survival.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Daniel H. Ahn
- Ohio State University Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH
| | | | - Todd DeWees
- Washington University in St. Louis, St. Louis, MO
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Amini R, Laughlin BS, Smith KW, Siwik VP, Adamas-Rappaport WJ, Fantry GT. "Flipped classroom" for academic and career advising: an innovative technique for medical student advising. Adv Med Educ Pract 2018; 9:371-376. [PMID: 29785150 PMCID: PMC5957052 DOI: 10.2147/amep.s162504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
INTRODUCTION Career advising for medical students can be challenging for both the student and the adviser. Our objective was to design, implement, and evaluate a "flipped classroom" style advising session. METHODS We performed a single-center cross-sectional study at an academic medical center, where a novel flipped classroom style student advising model was implemented and evaluated. In this model, students were provided a document to review and fill out prior to their one-on-one advising session. RESULTS Ninety-four percent (95% CI, 88%-100%) of the medical students surveyed felt that the advising session was more effective as a result of the outline provided and completed before the session and that the pre-advising document helped them gain a better understanding of the content to be discussed at the session. CONCLUSION Utilization of the flipped classroom style advising document was an engaging advising technique that was well received by students at our institution.
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Affiliation(s)
- Richard Amini
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
- Correspondence: Richard Amini, Department of Emergency Medicine, University of Arizona College of Medicine, PO Box 245057, Tucson, AZ 85724-5057, USA, Tel +1 520 626 9604, Fax +1 520 626 2480, Email
| | - Brady S Laughlin
- College of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Kathy W Smith
- Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Violet P Siwik
- Department of Family and Community Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | | | - George T Fantry
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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