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McDonald AM, Schneider CS, Stahl JM, Oster RA, Popple RA, Mayo CS. A focused review of statistical practices for relating radiation dose-volume exposure and toxicity. Radiat Oncol 2023; 18:57. [PMID: 36964622 PMCID: PMC10039562 DOI: 10.1186/s13014-023-02220-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/31/2023] [Indexed: 03/26/2023] Open
Abstract
PURPOSE Relating dose-volume histogram (DVH) information to patient outcomes is critical for outcomes research in radiation oncology, but this is statistically challenging. We performed this focused review of DVH toxicity studies to characterize current statistical approaches and determine the need for updated reporting recommendations. METHODS AND MATERIALS We performed a focused MEDLINE search to identify studies published in 5 radiation oncology specialty journals that associated dosimetry with toxicity outcomes in humans receiving radiotherapy between 2015 and 2021. Elements abstracted from each manuscript included the study outcome, organs-at-risk (OARs) considered, DVH parameters analyzed, summary of the analytic approach, use of multivariable statistics, goodness-of-fit reporting, completeness of model reporting, assessment of multicollinearity, adjustment for multiple comparisons, and methods for dichotomizing variables. Each study was also assessed for sufficient reporting to allow for replication of results. RESULTS The MEDLINE search returned 2,300 studies for review and 325 met the inclusion criteria for the analysis. DVH variables were dichotomized using cut points in 154 (47.4%) studies. Logistic regression (55.4% of studies) was the most common statistical method used to relate DVH to toxicity outcomes, followed by Cox regression (20.6%) and linear regression (12.0%). Multivariable statistical tests were performed in 226 (69.5%) studies; of these, the possibility of multicollinearity was addressed in 47.8% and model goodness-of-fit were reported in 32.6%. The threshold for statistical significance was adjusted to account for multiple comparisons in 41 of 196 (17.1%) studies that included multiple statistical comparisons. Twenty-eight (8.6%) studies were classified as missing details necessary to reproduce the study results. CONCLUSIONS Current practices of statistical reporting in DVH outcomes suggest that studies may be vulnerable to threats against internal and external validity. Recommendations for reporting are provided herein to guard against such threats and to promote cohesiveness among radiation oncology outcomes researchers.
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Affiliation(s)
- Andrew M McDonald
- Department of Radiation Oncology, Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, AL, USA.
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Craig S Schneider
- Department of Radiation Oncology, Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John M Stahl
- Department of Radiation Oncology, Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert A Oster
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard A Popple
- Department of Radiation Oncology, Hazelrig-Salter Radiation Oncology Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles S Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
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2
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Gao SJ, Jin L, Meadows HW, Shafman TD, Gross CP, Yu JB, Aerts HJWL, Miccio JA, Stahl JM, Mak RH, Decker RH, Kann BH. Prediction of Distant Metastases After Stereotactic Body Radiation Therapy for Early Stage NSCLC: Development and External Validation of a Multi-Institutional Model. J Thorac Oncol 2023; 18:339-349. [PMID: 36396062 DOI: 10.1016/j.jtho.2022.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 06/24/2022] [Revised: 11/03/2022] [Accepted: 11/06/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Distant metastases (DMs) are the primary driver of mortality for patients with early stage NSCLC receiving stereotactic body radiation therapy (SBRT), yet patient-level risk is difficult to predict. We developed and validated a model to predict individualized risk of DM in this population. METHODS We used a multi-institutional database of 1280 patients with cT1-3N0M0 NSCLC treated with SBRT from 2006 to 2015 for model development and internal validation. A Fine and Gray (FG) regression model was built to predict 1-year DM risk and compared with a random survival forests model. The higher performing model was evaluated on an external data set of 130 patients from a separate institution. Discriminatory performance was evaluated using the time-dependent area under the curve (AUC). Calibration was assessed graphically and with Brier scores. RESULTS The FG model yielded an AUC of 0.71 (95% confidence interval [CI]: 0.57-0.86) compared with the AUC of random survival forest at 0.69 (95% CI: 0.63-0.85) in the internal test set and was selected for further testing. On external validation, the FG model yielded an AUC of 0.70 (95% CI: 0.57-0.83) with good calibration (Brier score: 0.08). The model identified a high-risk patient subgroup with greater 1-year DM rates in the internal test (20.0% [3 of 15] versus 2.9% [7 of 241], p = 0.001) and external validation (21.4% [3 of 15] versus 7.8% [9 of 116], p = 0.095). A model nomogram and online application was made available. CONCLUSIONS We developed and externally validated a practical model that predicts DM risk in patients with NSCLC receiving SBRT which may help select patients for systemic therapy.
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Affiliation(s)
- Sarah J Gao
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Lan Jin
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Hugh W Meadows
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
| | - Hugo J W L Aerts
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts; Radiology and Nuclear Medicine, CARIM & GROW, Maastricht University, Maastricht, the Netherlands
| | - Joseph A Miccio
- Department of Radiation Oncology, Penn State Milton S. Hershey Medical Center, Camp Hill, Pennsylvania
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Raymond H Mak
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Benjamin H Kann
- Artificial Intelligence in Medicine (AIM) Program, Mass General Brigham, Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
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3
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Meredith RF, Bassler JR, McDonald AM, Stahl JM, Redden DT, Bonner JA. Biological Effective Radiation Dose for Multiple Myeloma Palliation. Adv Radiat Oncol 2023; 8:101214. [PMID: 37124314 PMCID: PMC10139858 DOI: 10.1016/j.adro.2023.101214] [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: 12/13/2022] [Accepted: 02/28/2023] [Indexed: 03/14/2023] Open
Abstract
Purpose Various radiation therapy (RT) dose/fractionation schedules are acceptable for palliation in multiple myeloma. Nine years of single-institution RT experience were reviewed to determine the influence of dose/fractionation and other factors pertinent to individualizing therapy. Methods and Materials In total, 152 items were identified from Current Procedural Terminology codes for multiple myeloma treatment from 2012 through June 30, 2021. After exclusions, 205 sites of radiation in 94 patients were reviewed. Data were captured from treatment planning and clinical records. To statistically assess the association between biological effective dose (BED10) and variables of interest, BED was first dichotomized to <24 Gy versus ≥24 Gy. Multivariate analysis used SAS software and a generalized estimating equation approach to account for multiple observations per patient. Results Fractions of 1.8 to 8 Gy were used in 1 to 25 fractions. Most patients had no significant toxicity. Grade 1 toxicity was more likely with greater BED radiation courses, as expected (20% vs 12% for BED <24 Gy). Pain relief was complete or very good for most sites, with <3% reporting no pain relief. Eleven sites in 9 patients required retreatment. All retreatment sites had palliation that was lasting, with a median of 22 months to last follow-up or death after repeat course (range, 0.5-106 months). There was a trend for better pain control and less risk of fracture retreatment with BED ≥24 Gy. Conclusions Most patients had good palliation without toxicity. BED ≥24 Gy caused 8% greater risk of grade 1 toxicity and trended toward better pain control plus reduced risk of fracture retreatment.
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Schneider CS, Hatic H, Das D, Cardan RA, Stahl JM, Bonner JA, Kole AJ. Patterns of Failure and Optimal Treatment Paradigm for Large, Inoperable, Node-Negative Non-small Cell Lung Cancer. Clin Lung Cancer 2022; 23:e408-e414. [PMID: 35680550 DOI: 10.1016/j.cllc.2022.05.005] [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: 02/18/2022] [Revised: 04/30/2022] [Accepted: 05/04/2022] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The ideal non-operative treatment for patients with large, node-negative non-small cell lung cancer (NSCLC) is poorly defined. To inform optimal treatment paradigms for this cohort, we examined patterns of failure and the impact of radiation therapy (RT) and chemotherapy receipt. MATERIALS AND METHODS Node-negative NSCLC patients with 5+ cm primary tumors receiving definitive RT at our institution were identified. Sites of initial progression were analyzed. Local progression, regional/distant progression, progression-free survival, and overall survival were analyzed via cumulative incidence function and Kaplan-Meier. Associations between local vs. regional/distant progression with treatment and clinicopathologic variables were assessed via univariable and multivariable competing risks regression. RESULTS AND CONCLUSION We identified 88 patients for analysis. Among patients with recurrent disease (N = 36), initial patterns of failure analysis showed that isolated distant (27.8%) and isolated regional progression (22.2%) were most common. Distant or regional failure as a component of initial failure was seen in 88.9% of patients who progressed, while isolated local failure was uncommon (11.1%). Univariable and multivariable competing risks regression showed that receipt of SBRT was associated with reduced risk of local progression (HR 0.23, P = .012), and receipt of chemotherapy was associated with reduced risk of regional/distant progression (HR 0.12, P = .040). In conclusion, patients with large, node-negative NSCLC treated with definitive RT are at high risk of regional and distant progression. SBRT correlates with a reduced risk of local failure while chemotherapy is associated with reduced regional/distant progression in this patient population. Ideal treatment may include SBRT when feasible with appropriate systemic therapy.
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Affiliation(s)
- Craig S Schneider
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Haris Hatic
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Devika Das
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Rex A Cardan
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - James A Bonner
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Adam J Kole
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL; O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL.
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Blitzer GC, Parekh AD, Chen S, Taparra K, Kahn JM, Fields EC, Stahl JM, Rosenberg SA, Buatti JM, Laucis AM, Wang Y, Mayhew DL, McDonald AM, Harari PM, Brower JV. Why an Increasing Number of Unmatched Residency Positions in Radiation Oncology? A Survey of Fourth-Year Medical Students. Adv Radiat Oncol 2021; 6:100743. [PMID: 34466713 PMCID: PMC8385400 DOI: 10.1016/j.adro.2021.100743] [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: 03/18/2021] [Revised: 05/05/2021] [Accepted: 06/09/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose The number of US fourth-year medical students applying to radiation oncology has decreased during the past few years. We conducted a survey of fourth-year medical students to examine factors that may be influencing the decision to pursue radiation oncology. Methods and Materials An anonymous online survey was sent to medical students at 9 participating US medical schools. Results A total of 232 medical students completed the survey. Of the 153 students who stated they were never interested in radiation oncology, 77 (50%) reported never having been exposed to the specialty as their reason for not pursuing radiation oncology. The job market was the most commonly cited factor among students who said they were once interested in but ultimately chose not to pursue radiation oncology. Conversely, the recent low pass rates for board examinations and a perception of a lack of diversity within radiation oncology had the least influence. Conclusions Despite discussion of potential measures to address this disquieting trend, there have been minimal formal attempts to characterize and address potential causes of a decreasing interest in radiation oncology. This study's data are consistent with previous research regarding the trend of decreased medical student interest in radiation oncology and may be used as part of ongoing introspective assessment to inform future change within radiation oncology.
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Affiliation(s)
- Grace C Blitzer
- Department of Human Oncology, University of Wisconsin, Madison, Wisconsin
| | - Akash D Parekh
- Department of Radiation Oncology, University of Florida, Gainesville, Florida
| | - Shuai Chen
- Department of Public Health Sciences, University of California-Davis, Sacramento, California
| | - Kekoa Taparra
- Gundersen Lutheran Health System, La Crosse, Wisconsin
| | - Jenna M Kahn
- Department of Radiation Oncology, Oregon Health and Science University, Portland, Oregon
| | - Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - John M Buatti
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Anna M Laucis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Yichu Wang
- Department of Mathematical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - David L Mayhew
- Department of Radiation Oncology, Tufts Medical Center, Boston, Massachusetts.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Andrew M McDonald
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul M Harari
- Department of Human Oncology, University of Wisconsin, Madison, Wisconsin
| | - Jeffrey V Brower
- Department of Human Oncology, University of Wisconsin, Madison, Wisconsin.,Radiation Oncology Associates-New England, Manchester, New Hampshire
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6
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Schneider CS, Oster RA, Hegde A, Dobelbower MC, Stahl JM, Kole AJ. Nonoperative Treatment of Large (5-7 cm), Node-Negative Non-Small Cell Lung Cancer Commonly Deviates From NCCN Guidelines. J Natl Compr Canc Netw 2021; 20:371-377.e5. [PMID: 34384045 DOI: 10.6004/jnccn.2021.7043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 04/05/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Optimal treatment of nonoperative patients with large, node-negative non-small cell lung cancer (NSCLC) is poorly defined. Current NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) recommend definitive radiotherapy (RT) with or without sequential chemotherapy and do not include concurrent chemoradiotherapy (chemoRT) as a treatment option. In this study, we identified factors that predict nonadherence to NCCN Guidelines. PATIENTS AND METHODS Patients who received definitive RT for nonmetastatic, node-negative NSCLC with tumor size of 5 to 7 cm were identified in the National Cancer Database from 2004 through 2016. Patients were evaluated by RT type (stereotactic body RT [SBRT], hypofractionated RT [HFRT], or conventionally fractionated RT [CFRT]) and chemotherapy use (none, sequential, or concurrent with RT). Patients were classified as receiving NCCN-adherent (RT with or without sequential chemotherapy) or NCCN-nonadherent (concurrent chemoRT) treatment. Demographic and clinical factors were assessed with logistic regression modeling. Overall survival was evaluated with Kaplan-Meier, log-rank, and univariable/multivariable Cox proportional hazards regression analyses. RESULTS Among 2,020 patients in our cohort, 32% received NCCN-nonadherent concurrent chemoRT, whereas others received NCCN-adherent RT alone (51%) or sequential RT and chemotherapy (17%). CFRT was most widely used (64% CFRT vs 22% SBRT vs 14% HFRT). Multivariable analysis revealed multiple factors to be associated with NCCN-nonadherent chemoRT: age ≤70 versus >70 years (odds ratio [OR] , 2.72; P<.001), treatment at a nonacademic facility (OR, 1.65; P<.001), and tumor size 6 to 7 cm versus 5 to 6 cm (OR, 1.27; P=.026). Survival was similar between the NCCN-nonadherent chemoRT and NCCN-adherent groups (hazard ratio, 1.00; P=.992) in multivariable analysis. CONCLUSIONS A substantial proportion of inoperable patients with large, node-negative NSCLC are not treated according to NCCN Guidelines and receive concurrent chemoRT. Younger patients with larger tumors receiving treatment at nonacademic medical centers were more likely to receive NCCN-nonadherent therapy, but adherence to NCCN Guidelines was not associated with differences in overall survival.
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Affiliation(s)
| | - Robert A Oster
- 2Division of Preventative Medicine, Department of Medicine, and
| | - Aparna Hegde
- 3Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Verma V, Wegner RE, Stahl JM, Barsky AR, Raghavan D, Busquets TE, Hoppe BS, Grover S, Friedberg JS, Simone CB. Impact of Detecting Occult Pathologic Nodal Disease During Resection for Malignant Pleural Mesothelioma. Clin Lung Cancer 2020; 21:e274-e285. [PMID: 32057688 DOI: 10.1016/j.cllc.2020.01.002] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/21/2019] [Accepted: 01/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lymph node (LN) involvement is a poor prognostic factor for malignant pleural mesothelioma (MPM). However, to our knowledge, postresection outcomes of node-negative (cN0/pN0), occult pathologic nodal disease (cN0/pN+), and clinical node-positive disease (cN+) have not been compared to date. PATIENTS AND METHODS The National Cancer Data Base was queried for newly diagnosed, resected MPM with known clinical/pathologic LN information. Three cohorts were compared: cN0/pN0, cN+, and cN0/pN+. Multivariable logistic regression examined predictors of pathologic nodal upstaging. Kaplan-Meier analysis with propensity matching assessed overall survival (OS); multivariate Cox proportional hazards modeling examined predictors thereof. RESULTS Of 1369 patients, 687 (50%) had cN0/pN0, 457 (33%) cN+, and 225 (16%) cN0/pN+ disease. Median follow-up was 29 months. In patients with cN0 disease, factors associated with pathologic nodal upstaging were younger age, greater number of examined LNs, and nonsarcomatoid histology (P < .05 for all). Relative to pN0 cases, occult LN involvement (65% being pN2) was associated with 51% higher hazard of mortality on multivariate analysis (P = .005). Following propensity matching, the OS of cN0/pN+ was similar to cN+ cases (P = .281). On multivariate analysis, the number of involved LNs (continuous variable, P = .013), but not nodal tumor, node, metastasis (TNM) classification or LN ratio (P > .05 for both), was associated with OS. CONCLUSION Detecting occult nodal disease during resection for cN0 MPM is associated with poorer prognosis, with similar survival as cN+ cases, underscoring the importance of routine preoperative pathologic nodal assessment for potentially resectable MPM. The number of involved LNs (rather than current location-based classification) may provide more robust prognostic stratification for future TNM staging.
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Affiliation(s)
- Vivek Verma
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew R Barsky
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Deepta Raghavan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Talia E Busquets
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida Proton Therapy Institute, Jacksonville, FL
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Joseph S Friedberg
- Department of Surgery, Division of Thoracic Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY.
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Holtzman AL, Stahl JM, Zhu S, Morris CG, Hoppe BS, Kirwan JE, Mendenhall NP. Does the Incidence of Treatment-Related Toxicity Plateau After Radiation Therapy: The Long-Term Impact of Integral Dose in Hodgkin's Lymphoma Survivors. Adv Radiat Oncol 2019; 4:699-705. [PMID: 31673663 PMCID: PMC6817558 DOI: 10.1016/j.adro.2019.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 01/17/2019] [Revised: 06/21/2019] [Accepted: 07/15/2019] [Indexed: 12/04/2022] Open
Abstract
Background Conventional radiation therapy (RT) has produced unprecedented cure rates in patients with Hodgkin's lymphoma (HL) but exposed large volumes of nontargeted tissue to radiation (integral dose). Objective Our goal was to report the effects of integral radiation dose on health outcomes in patients with at least 20 years of potential follow-up time. Methods and Materials We reviewed the medical records of 365 patients who were treated with RT for HL between 1965 and 1995. All patients were confirmed to have received primary RT with curative intent at our institution for de novo HL. Serious adverse events were classified as HL progression or death, grade ≥3 treatment- or staging-related acute or late effects, second malignancies, or cardiovascular events. Results The minimum potential follow-up time was 20 years, and the actual median follow-up time 22 years (range, <1-49 years) for all patients and 27 years (range, 5-49 years) for surviving patients. The overall survival rates at 5, 10, 20, 30, and 40 years were 86%, 76%, 64%, 44%, and 27%, respectively. The observed-to-expected ratio for second malignancy was 3.6 (95% confidence interval, 2.9-4.4). Grade ≥3 cardiovascular events occurred in 31% of all patients (n = 112). At the time of the most recent follow up, serious adverse events occurred in 70% of the entire cohort (n = 256) and 58% (n = 103), 77% (n = 103), and 93% (n = 50) among those with a potential 20, 30, and 40 years of follow up, respectively. Conclusions With increased survivorship, the long-term impact of the integral radiation dose may result in clinically significant adverse events, which suggests the importance of surveillance and affirms advances in both chemotherapy and RT that minimize the integral dose in future patients with HL.
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Affiliation(s)
- Adam L Holtzman
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama-Birmingham School of Medicine, Birmingham, Alabama
| | - Simeng Zhu
- Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, Michigan
| | - Christopher G Morris
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Bradford S Hoppe
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Jessica E Kirwan
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
| | - Nancy P Mendenhall
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, Florida
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Kann BH, Verma V, Stahl JM, Ross R, Dosoretz AP, Shafman TD, Gross CP, Park HS, Yu JB, Decker RH. Multi-institutional analysis of stereotactic body radiation therapy for operable early-stage non-small cell lung carcinoma. Radiother Oncol 2019; 134:44-49. [PMID: 31005223 DOI: 10.1016/j.radonc.2019.01.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 10/17/2018] [Revised: 01/11/2019] [Accepted: 01/21/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Although stereotactic body radiation therapy (SBRT) is the standard of care for inoperable early-stage non-small cell lung carcinoma (NSCLC), its role for medically operable patients remains controversial. To address this knowledge gap, we conducted a multi-institutional study to assess post-SBRT disease control and survival outcomes in medically operable patients. METHODS We conducted a retrospective cohort study including patients with biopsy-proven cT1-2N0M0 NSCLC treated with definitive SBRT (2006-2015). Per patient charts, inoperability referred to documentation of poor surgical candidacy with a given rationale for lack of resection. Charts of operable patients contained documentation of patients refusing surgery or choosing SBRT, without a documented rationale for inoperability. Subjects were excluded in cases of ambiguity regarding the aforementioned definitions and/or lack of clearly documented operability status. Endpoints included local failure (LF) and regional-distant failure, both evaluated with Fine and Gray competing risks regression; Kaplan-Meier methodology analyzed overall survival (OS) and progression-free survival (PFS). RESULTS Of 952 patients, 408 (42.9%) were operable, and 544 (57.1%) were inoperable. Median follow-up was 22 months. Two-year LF was 9.7% in operable patients and 8.2% in inoperable patients (p = 0.36). There was no statistical difference in regional-distant failure (p = 0.55) between cohorts. Operable patients experienced statistically higher OS (p = 0.04), but not PFS (p = 0.11). Respective 1-, 2-, and 3-year OS in operable patients were 85.4%, 66.2%, and 51.2%. CONCLUSIONS Although patients with operable NSCLC experience higher OS than their inoperable counterparts, disease-related outcomes are similar. These results may better inform shared decision-making between medically operable patients and their multidisciplinary providers.
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Affiliation(s)
- Benjamin H Kann
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA.
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, USA
| | - John M Stahl
- Department of Radiation Oncology, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Rudi Ross
- 21st Century Oncology, Fort Myers, USA
| | | | | | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA
| | - James B Yu
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, USA
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Kann BH, Miccio JA, Stahl JM, Ross R, Verma V, Dosoretz AP, Park HS, Shafman TD, Gross CP, Yu JB, Decker RH. Stereotactic body radiotherapy with adjuvant systemic therapy for early-stage non-small cell lung carcinoma: A multi-institutional analysis. Radiother Oncol 2018; 132:188-196. [PMID: 30391106 DOI: 10.1016/j.radonc.2018.10.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 06/15/2018] [Revised: 10/09/2018] [Accepted: 10/18/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Although adjuvant systemic therapy (ST) is often recommended for the treatment of patients with high-risk, early-stage non-small cell lung carcinoma (NSCLC) after surgery, there is little evidence supporting the use of ST with stereotactic body radiotherapy (SBRT). METHODS We conducted a retrospective cohort study using a multi-institutional database to identify consecutive patients with T1-3N0M0 NSCLC treated with definitive SBRT from 2006-2015. Treatment groups were defined as those who received SBRT + ST or SBRT alone. Regional-distant failure (RDF) was analyzed with Fine and Gray competing risks regression. Progression-free (PFS) and overall survival (OS) were analyzed with the Kaplan-Meier method and Cox regression. Additional comparisons were made after 2:1 nearest-neighbor propensity-score matching on clinical risk factors. RESULTS We identified 54 patients who received SBRT + ST. The most common ST regimen was a platinum doublet (n = 38; 70.4%). Compared with patients receiving SBRT (n = 1269), SBRT + ST patients were younger (median age: 70 v 77 years, p < 0.001), had larger tumors (>3 cm: 38.9% v 21.6%, p = 0.02) and higher T-stage (T2-3: 42.6% v 22.5%, p = 0.002). Compared with SBRT patients, SBRT + ST patients had lower 2-year RDF (3.1% v 16.9%, p = 0.02). On multivariable analysis, SBRT + ST was associated with reduced RDF (HR: 0.15, 95%CI: 0.04-0.62), with a trend toward improved PFS (HR: 0.70, 95%CI: 0.48-1.03), but not OS (HR: 0.74, 95%CI: 0.49-1.11). After propensity-score matching, the SBRT + ST cohort demonstrated improved RDF (HR: 0.17, 95%CI: 0.04-0.76) and PFS (HR: 0.59, 95%CI: 0.38-0.93). CONCLUSION In this multi-institutional analysis, adjuvant ST was independently associated with reduced RDF in early-stage NSCLC patients treated with SBRT.
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Affiliation(s)
- Benjamin H Kann
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, United States.
| | - Joseph A Miccio
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, United States
| | - John M Stahl
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, United States
| | - Rudi Ross
- 21st Century Oncology, Fort Myers, United States
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, United States
| | | | - Henry S Park
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, United States
| | | | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, United States
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, United States; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, United States
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, United States
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Stahl JM, Qian JM, Tien CJ, Carlson DJ, Chen Z, Ratner ES, Park HS, Damast S. Extended duration of dilator use beyond 1 year may reduce vaginal stenosis after intravaginal high-dose-rate brachytherapy. Support Care Cancer 2018; 27:1425-1433. [PMID: 30187220 DOI: 10.1007/s00520-018-4441-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vaginal dilators (VD) are recommended following vaginal or pelvic radiotherapy for patients with endometrial carcinoma (EC) to prevent vaginal stenosis (VS). The time course of VS is not fully understood and the optimal duration of VD use is unknown. METHODS We reviewed 243 stage IA-II EC patients who received adjuvant brachytherapy (BT) at an academic tertiary referral center. Patients were instructed to use their VD three times per week for at least 1-year duration. The primary outcome was development of grade ≥ 1 VS using CTCAEv4 criteria during the follow-up period. The log-rank test and multivariable Cox proportional hazards modeling were used to evaluate the effect of VD use (noncompliance vs. standard compliance [up to 1 year] vs. extended compliance [over 1 year]) on VS. RESULTS The median follow-up was 15.2 months over the 5-year study period. At 15 months, the incidence of VS was 38.8% for noncompliant patients, 33.5% for those with standard compliance, and 21.4% for those with extended compliance (median time to grade ≥ 1 VS was 17.5 months, 26.7 months, and not yet reached for these groups, respectively). On multivariable Cox regression analysis, extended compliance remained a significant predictor of reduced VS risk when compared to both noncompliance (HR 0.38, 95% CI 0.18-0.80, p = 0.012) and standard compliance (HR 0.43, 95% CI 0.20-0.89, p = 0.023). CONCLUSIONS The risk of VS persists beyond 1 year after BT. Extended VD compliance beyond 1 year may mitigate this risk.
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Affiliation(s)
- John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.
| | - Jack M Qian
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher J Tien
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Zhe Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Elena S Ratner
- Department of Gynecology and Reproductive Sciences, Section of Gynecologic Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
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12
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Kann BH, Yu JB, Stahl JM, Bond JE, Loiselle C, Chiang VL, Bindra RS, Gerrard JL, Carlson DJ. The impact of cobalt-60 source age on biologically effective dose in high-dose functional Gamma Knife radiosurgery. J Neurosurg 2018; 125:154-159. [PMID: 27903196 DOI: 10.3171/2016.6.gks161497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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: 11/06/2022]
Abstract
OBJECTIVE Functional Gamma Knife radiosurgery (GKRS) procedures have been increasingly used for treating patients with tremor, trigeminal neuralgia (TN), and refractory obsessive-compulsive disorder. Although its rates of toxicity are low, GKRS has been associated with some, if low, risks for serious sequelae, including hemiparesis and even death. Anecdotal reports have suggested that even with a standardized prescription dose, rates of functional GKRS toxicity increase after replacement of an old cobalt-60 source with a new source. Dose rate changes over the course of the useful lifespan of cobalt-60 are not routinely considered in the study of patients treated with functional GKRS, but these changes may be associated with significant variation in the biologically effective dose (BED) delivered to neural tissue. METHODS The authors constructed a linear-quadratic model of BED in functional GKRS with a dose-protraction factor to correct for intrafraction DNA-damage repair and used standard single-fraction doses for trigeminal nerve ablation for TN (85 Gy), thalamotomy for tremor (130 Gy), and capsulotomy for obsessive-compulsive disorder (180 Gy). Dose rate and treatment time for functional GKRS involving 4-mm collimators were derived from calibrations in the authors' department and from the cobalt-60 decay rate. Biologically plausible values for the ratio for radiosensitivity to fraction size (α/β) and double-strand break (DSB) DNA repair halftimes (τ) were estimated from published experimental data. The biphasic characteristics of DSB repair in normal tissue were accounted for in deriving an effective τ1 halftime (fast repair) and τ2 halftime (slow repair). A sensitivity analysis was performed with a range of plausible parameter values. RESULTS After replacement of the cobalt-60 source, the functional GKRS dose rate rose from 1.48 to 2.99 Gy/min, treatment time fell, and estimated BED increased. Assuming the most biologically plausible parameters, source replacement resulted in an immediate relative BED increase of 11.7% for GKRS-based TN management with 85 Gy, 15.6% for thalamotomy with 130 Gy, and 18.6% for capsulotomy with 180 Gy. Over the course of the 63-month lifespan of the cobalt-60 source, BED decreased annually by 2.2% for TN management, 3.0% for thalamotomy, and 3.5% for capsulotomy. CONCLUSIONS Use of a new cobalt-60 source after replacement of an old source substantially increases the predicted BED for functional GKRS treatments for the same physical dose prescription. Source age, dose rate, and treatment time should be considered in the study of outcomes after high-dose functional GKRS treatments. Animal and clinical studies are needed to determine how this potential change in BED contributes to GKRS toxicity and whether technical adjustments should be made to reduce dose rates or prescription doses with newer cobalt-60 sources.
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Affiliation(s)
| | - James B Yu
- Departments of 1 Therapeutic Radiology and
| | | | | | | | - Veronica L Chiang
- Neurosurgery, Yale University School of Medicine, New Haven, Connecticut; and
| | | | - Jason L Gerrard
- Neurosurgery, Yale University School of Medicine, New Haven, Connecticut; and
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13
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Bledsoe TJ, Park HS, Stahl JM, Yarbrough WG, Burtness BA, Decker RH, Husain ZA. Response. J Natl Cancer Inst 2018; 110:433-434. [PMID: 29121329 DOI: 10.1093/jnci/djx230] [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: 08/31/2017] [Accepted: 09/28/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Trevor J Bledsoe
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | | | - Barbara A Burtness
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Zain A Husain
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
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14
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Patel KR, Martinez A, Stahl JM, Logan SJ, Perricone AJ, Ferris MJ, Buchwald ZS, Chowdhary M, Delman KA, Monson DK, Oskouei SV, Reimer NB, Cardona K, Edgar MA, Godette KD. Increase in PD-L1 expression after pre-operative radiotherapy for soft tissue sarcoma. Oncoimmunology 2018; 7:e1442168. [PMID: 29900051 PMCID: PMC5993497 DOI: 10.1080/2162402x.2018.1442168] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/14/2018] [Indexed: 01/01/2023] Open
Abstract
Soft tissue sarcomas (STS) have minimal expression of PD-L1, a biomarker for PD-1 therapy efficacy. Radiotherapy (RT) has been shown to increase PD-L1 expression pre-clinically. We examined the expression of PD-L1, pre- and post-RT, in 46 Stage II-III STS patients treated with pre-operative RT (50-50.4 Gy in 25-28 fractions) followed by resection. Five additional patients who did not receive RT were utilized as controls. PD-L1 expression on biopsy and resection samples was evaluated by immunochemistry using the anti PD-L1 monoclonal antibody (E1L3 N clone; Cell Signaling). Greater than 1% membranous staining was considered positive PD-L1 expression. Changes in PD-L1 expression were analyzed via the Fisher exact test. Kaplan-Meier statistics were used to correlate PD-L1 expression to distant metastases (DM) rate. The majority of STS were T2b (87.0%), high-grade (80.4%), undifferentiated pleomorphic histology (71.7%), and originated from the extremities (84.6%). Zero patients demonstrated PD-L1 tumor expression pre-RT. Post-RT, 5 patients (10.9%) demonstrated PD-L1 tumor expression (p = 0.056). Tumor associated macrophages (TAM) expression of PD-L1 increased after RT: 15.2% to 45.7% (p = 0.003). Samples from controls demonstrated no baseline (0%) or change in tumor PD-L1 expression. Freedom from DM was lower for patients with PD-L1 TAM expression post-RT (3 years: 49.7% vs. 87.8%, log-rank p = 0.006); TAM PD-L1 positivity remained an independent predictor for DM on multivariate analyses (Hazard ratio - 0.16, 95% confidence interval: 0.034-0.721, p = 0.042). PD-L1 expression on human STS tumor and TAM appears to elevate after pre-operative RT. Expression of PD-L1 on TAM after RT was associated with a higher rate of DM.
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Affiliation(s)
- Kirtesh R Patel
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Anthony Martinez
- Deparment of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - John M Stahl
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, USA
| | - Suzanna J Logan
- Deparment of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Adam J Perricone
- Deparment of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew J Ferris
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Zachary S Buchwald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Mudit Chowdhary
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Keith A Delman
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - David K Monson
- Division of Orthopaedic Oncology, Department of Orthopedic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Shervin V Oskouei
- Division of Orthopaedic Oncology, Department of Orthopedic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicholas B Reimer
- Division of Orthopaedic Oncology, Department of Orthopedic Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark A Edgar
- Deparment of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Karen D Godette
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
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15
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Qian JM, Stahl JM, Young MR, Ratner E, Damast S. Impact of vaginal cylinder diameter on outcomes following brachytherapy for early stage endometrial cancer. J Gynecol Oncol 2018; 28:e84. [PMID: 29027402 PMCID: PMC5641534 DOI: 10.3802/jgo.2017.28.e84] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/16/2017] [Accepted: 08/10/2017] [Indexed: 01/23/2023] Open
Abstract
Objective To examine the outcomes (tolerability, toxicity, and recurrence) of vaginal brachytherapy (VBT) among endometrial cancer (EC) patients treated with small cylinder size. Methods Patients with EC who received adjuvant VBT between September 2011 and December 2015 were reviewed. Patients were fitted with the largest vaginal cylinder they could comfortably accommodate, from 2.0–3.0 cm diameter. Small cylinders were defined as size 2.3 cm or less. Patient, tumor, or treatment characteristics were correlated with need for small cylinders. Treatment tolerability, measures of gastrointestinal (GI), genitourinary (GU), and vaginal toxicity, and rates of recurrence were analyzed. Results Three hundred four patients were included. Small cylinders were used in 51 patients (17%). Normal body mass index (BMI; p<0.001), nulligravidity (p<0.001), and shorter vaginal length (p<0.001) were associated with small cylinder size. There was no acute or late grade 3 toxicity. Rates of acute (grade 1–2) GI, GU, or vaginal symptoms were low (10%, 11%, and 19%, respectively). Small cylinder size was associated with increased likelihood of reporting acute GI (p<0.05) but not GU or vaginal symptoms. Small cylinder size was associated with higher risk of grade 1–2 vaginal stenosis (odds ratio [OR]=4.7; 95% confidence interval [CI]=1.5–14.7; p=0.007). There was no association between cylinder size and recurrence rate (p=0.55). Conclusion VBT is generally very well tolerated, however, patients fitted with smaller cylinders (commonly nulligravid and low BMI) may have increased side effects. Further study to improve the dosimetry of VBT for patients requiring small cylinders may be worthwhile.
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Affiliation(s)
- Jack M Qian
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - John M Stahl
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Melissa R Young
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Elena Ratner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA.
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Stahl JM, Corso CD, Verma V, Park HS, Nath SK, Husain ZA, Simone CB, Kim AW, Decker RH. (P085) Trends in Stereotactic Body Radiation Therapy for Stage I Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.02.181] [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] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Bledsoe TJ, Park HS, Stahl JM, Yarbrough WG, Burtness BA, Decker RH, Husain ZA. (S027) Hypofractionated Radiotherapy Is associated With Improved Overall Survival Among Patients With Early-Stage Glottic Cancer. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.02.063] [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] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Bledsoe TJ, Park HS, Stahl JM, Yarbrough WG, Burtness BA, Decker RH, Husain ZA. Hypofractionated Radiotherapy for Patients with Early-Stage Glottic Cancer: Patterns of Care and Survival. J Natl Cancer Inst 2017; 109:3611465. [DOI: 10.1093/jnci/djx042] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/24/2017] [Indexed: 11/13/2022] Open
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19
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An Y, Park HS, Kelly JR, Stahl JM, Yarbrough WG, Burtness BA, Contessa JN, Decker RH, Koshy M, Husain ZA. The prognostic value of extranodal extension in human papillomavirus-associated oropharyngeal squamous cell carcinoma. Cancer 2017; 123:2762-2772. [DOI: 10.1002/cncr.30598] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/05/2017] [Accepted: 01/08/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Yi An
- Department of Therapeutic Radiology; Yale University School of Medicine; New Haven Connecticut
| | - Henry S. Park
- Department of Therapeutic Radiology; Yale University School of Medicine; New Haven Connecticut
| | - Jacqueline R. Kelly
- Department of Therapeutic Radiology; Yale University School of Medicine; New Haven Connecticut
| | - John M. Stahl
- Department of Therapeutic Radiology; Yale University School of Medicine; New Haven Connecticut
| | - Wendell G. Yarbrough
- Division of Otolaryngology, Department of Surgery; Yale University School of Medicine; New Haven Connecticut
- Department of Pathology; Yale University School of Medicine; New Haven Connecticut
- Yale Cancer Center; New Haven Connecticut
| | - Barbara A. Burtness
- Yale Cancer Center; New Haven Connecticut
- Department of Medical Oncology; Yale University School of Medicine; New Haven Connecticut
| | - Joseph N. Contessa
- Department of Therapeutic Radiology; Yale University School of Medicine; New Haven Connecticut
- Yale Cancer Center; New Haven Connecticut
| | - Roy H. Decker
- Department of Therapeutic Radiology; Yale University School of Medicine; New Haven Connecticut
- Yale Cancer Center; New Haven Connecticut
| | - Matthew Koshy
- Department of Radiation Oncology; University of Chicago School of Medicine; Chicago Illinois
| | - Zain A. Husain
- Department of Therapeutic Radiology; Yale University School of Medicine; New Haven Connecticut
- Yale Cancer Center; New Haven Connecticut
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20
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Kole AJ, Stahl JM, Park HS, Khan SA, Johung KL. Predictors of Nonadherence to NCCN Guideline Recommendations for the Management of Stage I Anal Canal Cancer. J Natl Compr Canc Netw 2017; 15:355-362. [PMID: 28275036 DOI: 10.6004/jnccn.2017.0035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/30/2016] [Indexed: 11/17/2022]
Abstract
Background: Definitive chemoradiotherapy (CRT) is recommended by the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Anal Carcinoma for all patients with stage I anal canal cancer. Because these patients were not well represented in clinical trials establishing CRT as standard therapy, it is unclear whether NCCN recommendations are being closely followed for stage I disease. This study identified factors that predict for NCCN Guideline-concordant versus NCCN Guideline-discordant care. Methods: Using the National Cancer Data Base, we identified patients diagnosed with anal canal carcinoma from 2004 to 2012 who received concurrent CRT (radiotherapy [RT] 45.0-59.4 Gy with multiagent chemotherapy), RT alone (45.0-59.4 Gy), or surgical procedure alone (local tumor destruction, tumor excision, or abdominoperineal resection). Demographic and clinicopathologic factors were analyzed using the chi-square test and logistic regression modeling. Results: A total of 1,082 patients with histologically confirmed stage I anal cancer were identified, among whom 665 (61.5%) received CRT, 52 (4.8%) received RT alone, and 365 (33.7%) received only a surgical procedure. Primary analyses were restricted to patients receiving CRT or excision alone, as these were most common. Multivariable analysis identified factors independently associated with reduced odds of CRT receipt: low versus intermediate/high tumor grade (adjusted odds ratio [AOR], 0.21; 95% CI, 0.14-0.29; P<.001), tumor size <1 cm vs 1 to 2 cm (AOR, 0.24; 95% CI, 0.17-0.35; P<.001), age ≥70 versus 50 to 69 years (AOR, 0.36; 95% CI, 0.24-0.54; P<.001), male sex (AOR, 0.63; 95% CI, 0.45-0.90; P=.009), and treatment at an academic versus a non-academic facility (AOR, 0.58; 95% CI, 0.41-0.81; P=.002). Conclusions: Despite the NCCN recommendation of CRT for stage I anal cancer, at least one-third of patients appear to be receiving guideline-discordant management. Excision alone is more common for patients who are elderly, are male, have small or low-grade tumors, or were evaluated at academic facilities.
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Affiliation(s)
- Adam J Kole
- Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
| | - John M Stahl
- Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
| | - Henry S Park
- Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
| | - Sajid A Khan
- Department of Surgery, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
| | - Kimberly L Johung
- Department of Therapeutic Radiology, Surgical Oncology Section, Yale School of Medicine, New Haven, Connecticut
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21
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Verma V, Shostrom VK, Kumar SS, Zhen W, Hallemeier CL, Braunstein SE, Holland J, Harkenrider MM, S Iskhanian A, Neboori HJ, Jabbour SK, Attia A, Lee P, Alite F, Walker JM, Stahl JM, Wang K, Bingham BS, Hadzitheodorou C, Decker RH, McGarry RC, Simone CB. Multi-institutional experience of stereotactic body radiotherapy for large (≥5 centimeters) non-small cell lung tumors. Cancer 2017; 123:688-696. [PMID: 27741355 PMCID: PMC10905610 DOI: 10.1002/cncr.30375] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/31/2016] [Accepted: 09/09/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) is the standard of care for patients with nonoperative, early-stage non-small cell lung cancer (NSCLC) measuring < 5 cm, but its use among patients with tumors measuring ≥5 cm is considerably less defined, with the existing literature limited to small, single-institution reports. The current multi-institutional study reported outcomes evaluating the largest such population reported to date. METHODS Clinical/treatment characteristics, outcomes, toxicities, and patterns of failure were assessed in patients with primary NSCLC measuring ≥5 cm without evidence of distant/lymph node metastasis who underwent SBRT using ≤5 fractions. Statistics included Kaplan-Meier survival analyses and univariate/multivariate Cox proportional hazards models. RESULTS A total of 92 patients treated from 2004 through 2016 were analyzed from 12 institutions. The median follow-up was 12 months (15 months in survivors). The median age and tumor size among the patients were 73 years (range, 50-95 years) and 5.4 cm (range, 5.0-7.5 cm), respectively. The median dose/fractionation was 50 Gray/5 fractions. The actuarial local control rates at 1 year and 2 years were 95.7% and 73.2%, respectively. The disease-free survival rate was 72.1% and 53.5%, respectively, at 1 year and 2 years. The 1-year and 2-year disease-specific survival rates were 95.5% and 78.6%, respectively. The median, 1-year, and 2-year overall survival rates were 21.4 months, 76.2%, and 46.4%, respectively. On multivariate analysis, lung cancer history and pre-SBRT positron emission tomography maximum standardized uptake value were found to be associated with overall survival. Posttreatment failures were most commonly distant (33% of all disease recurrences), followed by local (26%) and those occurring elsewhere in the lung (23%). Three patients had isolated local failures. Grade 3 to 4 toxicities included 1 case (1%) and 4 cases (4%) of grade 3 dermatitis and radiation pneumonitis, respectively (toxicities were graded according to the Common Terminology Criteria for Adverse Events [version 4.0]). Grades 2 to 5 radiation pneumonitis occurred in 11% of patients. One patient with a tumor measuring 7.5 cm and a smoking history of 150 pack-years died of radiation pneumonitis. CONCLUSIONS The results of the current study, which is the largest study of patients with NSCLC measuring ≥5 cm reported to date, indicate that SBRT is a safe and efficacious option. Cancer 2017;123:688-696. © 2016 American Cancer Society.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Valerie K Shostrom
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Sameera S Kumar
- Department of Radiation Oncology, University of Kentucky, Lexington, Kentucky
| | - Weining Zhen
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Steve E Braunstein
- Department of Radiation Oncology, University of California at San Francisco, San Francisco, California
| | - John Holland
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Adrian S Iskhanian
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Hanmanth J Neboori
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Percy Lee
- Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Fiori Alite
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, Illinois
| | - Joshua M Walker
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon
| | - John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Kyle Wang
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Brian S Bingham
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christina Hadzitheodorou
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Ronald C McGarry
- Department of Radiation Oncology, University of Kentucky, Lexington, Kentucky
| | - Charles B Simone
- Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Stahl JM, Walther Z, Chang BW, Hochster HS, Johung KL. A Long-Term Survivor of Metastatic Pancreatic Adenocarcinoma: Free of Recurrence 12 Years After Treatment of Oligometastatic Disease. Cureus 2017; 9:e1007. [PMID: 28293485 PMCID: PMC5333949 DOI: 10.7759/cureus.1007] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Aggressive local therapy for patients with oligometastatic pancreatic ductal adenocarcinoma (PDAC) has traditionally not been pursued due to high rates of distant progression. We describe a 62-year-old male initially presenting with resectable PDAC who underwent the Whipple procedure but developed multiple liver metastases within two months of starting adjuvant gemcitabine. Oxaliplatin was added to the regimen and complete resolution of the liver lesions resulted. He remained disease-free for five years until re-staging revealed a small lung nodule. This was resected and confirmed to be metastatic PDAC. After additional adjuvant gemcitabine, the patient remained free of recurrence for 12 years after diagnosis of metastatic disease and ultimately passed away from complications of ascending cholangitis associated with stricture at the biliary-enteric anastomosis site. He had no evidence of disease recurrence at the time of death. Next-generation sequencing of the tumor was unrevealing, showing only an activating mutation of KRAS and a deleterious mutation of tumor protein p53 (TP53). Our case suggests that while the prognosis for metastatic PDAC is poor, the population is nonetheless heterogeneous. Prognostic biomarkers are needed for the identification of patients for whom aggressive local treatment of oligometastatic PDAC may be warranted.
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Affiliation(s)
- John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine
| | - Zenta Walther
- Department of Pathology, Yale University School of Medicine
| | - Bryan W Chang
- Radiation Oncology, Torrance Memorial Medical Center
| | | | - Kimberly L Johung
- Department of Therapeutic Radiology, Yale University School of Medicine
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Verma V, Simone CB, Allen PK, Gajjar SR, Shah C, Zhen W, Harkenrider MM, Hallemeier CL, Jabbour SK, Matthiesen CL, Braunstein SE, Lee P, Dilling TJ, Allen BG, Nichols EM, Attia A, Zeng J, Biswas T, Paximadis P, Wang F, Walker JM, Stahl JM, Daly ME, Decker RH, Hales RK, Willers H, Videtic GMM, Mehta MP, Lin SH. Multi-Institutional Experience of Stereotactic Ablative Radiation Therapy for Stage I Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 97:362-371. [PMID: 28011047 PMCID: PMC10905608 DOI: 10.1016/j.ijrobp.2016.10.041] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 10/19/2016] [Accepted: 10/26/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE For inoperable stage I (T1-T2N0) small cell lung cancer (SCLC), national guidelines recommend chemotherapy with or without conventionally fractionated radiation therapy. The present multi-institutional cohort study investigated the role of stereotactic ablative radiation therapy (SABR) for this population. METHODS AND MATERIALS The clinical and treatment characteristics, toxicities, outcomes, and patterns of failure were assessed in patients with histologically confirmed stage T1-T2N0M0 SCLC. Kaplan-Meier analysis was used to evaluate the survival outcomes. Univariate and multivariate analyses identified predictors of outcomes. RESULTS From 24 institutions, 76 lesions were treated in 74 patients (median follow-up 18 months). The median age and tumor size was 72 years and 2.5 cm, respectively. Chemotherapy and prophylactic cranial irradiation were delivered in 56% and 23% of cases, respectively. The median SABR dose and fractionation was 50 Gy and 5 fractions. The 1- and 3-year local control rate was 97.4% and 96.1%, respectively. The median disease-free survival (DFS) duration was 49.7 months. The DFS rate was 58.3% and 53.2% at 1 and 3 years, respectively. The median, 1-year, and 3-year disease-specific survival was 52.3 months, 84.5%, and 64.4%, respectively. The median, 1-year, and 3-year overall survival (OS) was 17.8 months, 69.9%, and 34.0% respectively. Patients receiving chemotherapy experienced an increased median DFS (61.3 vs 9.0 months; P=.02) and OS (31.4 vs 14.3 months; P=.02). The receipt of chemotherapy independently predicted better outcomes for DFS/OS on multivariate analysis (P=.01). Toxicities were uncommon; 5.2% experienced grade ≥2 pneumonitis. Post-treatment failure was most commonly distant (45.8% of recurrence), followed by nodal (25.0%) and "elsewhere lung" (20.8%). The median time to each was 5 to 7 months. CONCLUSIONS From the findings of the largest report of SABR for stage T1-T2N0 SCLC to date, SABR (≥50 Gy) with chemotherapy should be considered a standard option.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Charles B Simone
- Department of Radiation Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Pamela K Allen
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Weining Zhen
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Loyola University Stritch School of Medicine, Maywood, Illinois
| | | | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, New Jersey
| | - Chance L Matthiesen
- Department of Radiation Oncology, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, Oklahoma
| | - Steve E Braunstein
- Department of Radiation Oncology, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Percy Lee
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Thomas J Dilling
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Bryan G Allen
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington
| | - Tithi Biswas
- Department of Radiation Oncology, University Hospitals Siedman Cancer Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter Paximadis
- Division of Radiation Oncology, Department of Oncology, Barbara Ann Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, Michigan
| | - Fen Wang
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, Kansas
| | - Joshua M Walker
- Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon
| | - John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Megan E Daly
- Department of Radiation Oncology, University of California, Davis, Comprehensive Cancer Center, Sacramento, California
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Russell K Hales
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Henning Willers
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Gregory M M Videtic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Minesh P Mehta
- Miami Cancer Institute, Baptist Health South Florida, Coral Gables, Florida
| | - Steven H Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
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Stahl JM, Corso CD, Verma V, Park HS, Nath SK, Husain ZA, Simone CB, Kim AW, Decker RH. Trends in stereotactic body radiation therapy for stage I small cell lung cancer. Lung Cancer 2016; 103:11-16. [PMID: 28024690 DOI: 10.1016/j.lungcan.2016.11.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/25/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVES We aimed to report trends in stereotactic body radiation therapy (SBRT) utilization, dose prescriptions, and chemotherapy administration for stage I small cell lung cancer (SCLC) in the United States. MATERIALS AND METHODS The National Cancer Data Base (NCDB) was used to identify patients with cT1-2 N0 SCLC treated with SBRT between 2004 and 2013. Trends in SBRT use and dose prescription were analyzed over time. Multivariable logistic regression was used to determine factors associated with the administration of chemotherapy with SBRT. The Kaplan-Meier method was used to estimate overall survival. RESULTS Of 9265 patients with clinical stage I SCLC who were examined for initial treatment allocation, 285 were treated with SBRT and represented the subject of the primary analysis. SBRT utilization increased from 2004 (0.4% of all stage I patients diagnosed that year) to 2013 (6.4%). During this same time period, definitive surgical management also increased from 14.9% of all patients in 2004 to 28.5% in 2013. The median SBRT biologically effective dose (BED10) was 112.5Gy (range, 72-290) and only 33 out of 285 (11.6%) received a BED10<100Gy. Nearly half of all patients (130/285, 45.6%) received chemotherapy, with 42.7% of those patients receiving their chemotherapy prior to SBRT. On multivariable logistic regression, only age<75 (the median) vs. ≥75years (OR 4.97, 95% CI 2.96-8.35, p<0.001) and year of diagnosis 2004-2008 vs. 2009-2013 (OR 2.58, 95% CI 1.27-5.26, p=0.009) were predictive of chemotherapy use with SBRT. After median follow up of 45 months, the median survival was 23.5 months. CONCLUSIONS Our findings suggest that SBRT utilization for stage I SCLC has increased between 2004 and 2013, highlighting the need for additional research to validate the feasibility of this management approach for inoperable patients.
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Affiliation(s)
- John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States
| | - Christopher D Corso
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, United States
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States
| | - Sameer K Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States
| | - Zain A Husain
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States
| | - Charles B Simone
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Anthony W Kim
- Department of Surgery, Section of Thoracic Surgery, Yale University School of Medicine, New Haven, CT, United States
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, United States.
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Stahl JM, Ross R, Harder EM, Mancini BR, Soulos PR, Finkelstein SE, Shafman TD, Dosoretz AP, Evans SB, Husain ZA, Yu JB, Gross CP, Decker RH. The Effect of Biologically Effective Dose and Radiation Treatment Schedule on Overall Survival in Stage I Non-Small Cell Lung Cancer Patients Treated With Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2016; 96:1011-1020. [PMID: 27869080 DOI: 10.1016/j.ijrobp.2016.08.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 07/23/2016] [Accepted: 08/23/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the effect of biologically effective dose (BED10) and radiation treatment schedule on overall survival (OS) in patients with early-stage non-small cell lung cancer (NSCLC) undergoing stereotactic body radiation therapy (SBRT). METHODS AND MATERIALS Using data from 65 treatment centers in the United States, we retrospectively reviewed the records of T1-2 N0 NSCLC patients undergoing SBRT alone from 2006 to 2014. Biologically relevant covariates, including dose per fraction, number of fractions, and time between fractions, were used to quantify BED10 and radiation treatment schedule. The linear-quadratic equation was used to calculate BED10 and to generate a dichotomous dose variable of <105 Gy versus ≥105 Gy BED10. The primary outcome was OS. We used the Kaplan-Meier method, the log-rank test, and Cox proportional hazards regression with propensity score matching to determine whether prescription BED10 was associated with OS. RESULTS We identified 747 patients who met inclusion criteria. The median BED10 was 132 Gy, and 59 (7.7%) had consecutive-day fractions. Median follow-up was 41 months, and 452 patients (60.5%) had died by the conclusion of the study. The 581 patients receiving ≥105 Gy BED10 had a median survival of 28 months, whereas the 166 patients receiving <105 Gy BED10 had a median survival of 22 months (log-rank, P=.01). Radiation treatment schedule was not a significant predictor of OS on univariable analysis. After adjusting for T stage, sex, tumor histology, and Eastern Cooperative Oncology Group performance status, BED10 ≥105 Gy versus <105 Gy remained significantly associated with improved OS (hazard ratio 0.78, 95% confidence interval 0.62-0.98, P=.03). Propensity score matching on imbalanced variables within high- and low-dose cohorts confirmed a survival benefit with higher prescription dose. CONCLUSIONS We found that dose escalation to 105 Gy BED10 and beyond may improve survival in NSCLC patients treated with SBRT.
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Affiliation(s)
- John M Stahl
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Rudi Ross
- 21st Century Oncology, Fort Myers, Florida
| | - Eileen M Harder
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Brandon R Mancini
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - Suzanne B Evans
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Zain A Husain
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - James B Yu
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut
| | - Roy H Decker
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, Connecticut.
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Stahl JM, Park HS, Silasi DA, Azodi M, Damast S. Influence of robotic-assisted laparoscopic hysterectomy on vaginal cuff healing and brachytherapy initiation in endometrial carcinoma patients. Pract Radiat Oncol 2016; 6:226-232. [DOI: 10.1016/j.prro.2015.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 08/11/2015] [Accepted: 09/28/2015] [Indexed: 10/21/2022]
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Abstract
Abstract
BACKGROUND
Despite a high success rate in the stereotactic radiosurgical treatment of intracranial arteriovenous malformations (AVMs) that cannot be safely resected with microsurgery, some patients must be managed after treatment failure.
OBJECTIVE
To provide an update on the use of repeat linear accelerator radiosurgery as a treatment for failed AVM radiosurgery at the University of Florida.
METHODS
We reviewed 103 patients who underwent repeat radiosurgical treatment for residual AVM at the University of Florida between December 1991 and December 2007. Each of these patients had at least 2 radiosurgical treatments for the same AVM. Patient information, including AVM nidus volume, prescription dose, age, and sex, was collected at the time of initial treatment and again at the time of retreatment. Patients were followed up after treatment with magnetic resonance, computed tomography, and angiographic imaging at standard intervals to determine the status of their AVM. The median follow-up after retreatment was 31 months.
RESULTS
Between the first and second treatments, the median AVM nidus volume was decreased by 69% (from a median volume of 12.7 to 4.0 cm3), allowing the median prescribed dose to be increased from 1500 cGy on initial treatment to 1750 cGy on retreatment. The final obliteration rate on retreatment was 65.3%. After salvage retreatment, 5 patients (4.9%) experienced radiation-induced complications, and 6 patients (5.8%) experienced posttreatment hemorrhage.
CONCLUSION
Repeat radiosurgery is a safe and effective salvage treatment for AVMs.
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Affiliation(s)
- John M. Stahl
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Yueh-Yun Chi
- Department of Epidemiology and Health Policy Research, University of Florida, Gainesville, Florida
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Abstract
The physiological effects of gamma-hydroxybutyrate (GHB) are complex and not yet clearly defined. GHB has been labeled as a recreational drug and is reported to be frequently coabused with ethanol (ETH). Other studies have yielded discrepant results as to the interaction between GHB and ETH. Thus, the present study investigated extensively the discriminative stimulus of GHB and ETH and a mixture of the two compounds. Thirty male Long-Evans rats were divided into three groups and trained to discriminate doses of either 300 mg/kg GHB, 1000 mg/kg ETH, or a mixture (MIX: 150 mg/kg GHB+500 mg/kg ETH) from vehicle on a two-lever fixed-ratio (FR) 10 schedule of food reinforcement. Dose-response curves were attained in each group with its respective training drugs. GHB and ETH did not cross-generalize in the ETH- and GHB-trained rats, respectively. However, when the effects of the MIX were tested in the GHB- and ETH-trained rats, a greater than additive response was observed. Testing also revealed that the MIX-trained rats did not perceive a novel stimulus but a near-equal contribution from GHB and ETH. This study provides evidence of a complex relationship between GHB and ETH and opposes previous work reporting cross-generalization between GHB and ETH.
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Affiliation(s)
- B R Metcalf
- Psychology Program, Hawaii Pacific University, 1188 Fort Street Mall, Honolulu, HI 96813, USA.
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29
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Davis HM, Carpenter DC, Stahl JM, Zhang W, Hynicka WP, Griswold DE. Human granulocyte CD11b expression as a pharmacodynamic biomarker of inflammation. J Immunol Methods 2000; 240:125-32. [PMID: 10854607 DOI: 10.1016/s0022-1759(00)00183-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A method has been developed for the direct quantification of the CD11b integrin on granulocytes by flow cytometric analysis of whole blood specimens following either LTB(4) or lipopolysaccharide (LPS) stimulation. This method has utility in evaluating the pharmacodynamic action of either LTB(4) receptor antagonists or immune cell modulators in effecting CD11b integrin expression and granulocyte activation in human subjects administered such drugs. Previous studies using CD11b as a biomarker of granulocyte activation have faltered because of the difficulty in controlling the activation state of the granulocyte following removal of blood from subjects. The present study has made use of a newly validated method using either LTB(4) or LPS to stimulate CD11b expression on granulocytes and has been used, as one measure, in the evaluation of LPS activity when administered to normal human volunteers.
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Affiliation(s)
- H M Davis
- SmithKline Beecham Pharmaceuticals, Pharmacodynamics and Exploratory Research Laboratory, Clinical Pharmacology Unit, Presbyterian Medical Center, Philadelphia, PA 19104, USA.
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Abstract
We are analyzing highly conserved heat shock genes of unknown or unclear function with the aim of determining their cellular role. Hsp15 has previously been shown to be an abundant nucleic acid-binding protein whose synthesis is induced massively at the RNA level upon temperature upshift. We have now identified that the in vivo target of Hsp15 action is the free 50S ribosomal subunit. Hsp15 binds with very high affinity (K(D) <5 nM) to this subunit, but only when 50S is free, not when it is part of the 70S ribosome. In addition, the binding of Hsp15 appears to correlate with a specific state of the mature, free 50S subunit, which contains bound nascent chain. This provides the first evidence for a so far unrecognized abortive event in translation. Hsp15 is suggested to be involved in the recycling of free 50S subunits that still carry a nascent chain. This gives Hsp15 a very different functional role from all other heat shock proteins and points to a new aspect of translation.
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Affiliation(s)
- P Korber
- Department of Biology, University of Michigan, Ann Arbor, MI 48109-1048, USA
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31
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Abstract
The effect on alveolar oxygen fraction (FAO2) of insufflating oxygen under a mask (or through an inflow nipple provided in the mask) during simulated mouth-to-mask ventilation was investigated using a lung model. A variety of commercially produced masks were evaluated. Two patterns of artificial ventilation were applied: 1. 500 ml tidal volume at 20 breaths per minute, and 2. 900 ml tidal volume at 12 breaths per minute. The ventilating gas mixture was oxygen 16% in nitrous oxide, and oxygen was insufflated at flow rates of 2, 4, 6, 8, 10, 12 or 14 litres per minute. The rate of rise of FAO2 and the equilibrium FAO2 attained were greatest at high oxygen inflow rates. The relationship between oxygen flow and FAO2 was not linear however, and an oxygen flow rate of 10 l/min was adequate to generate FAO2's around 50% with either ventilatory pattern. The equilibrium FAO2 achieved was greater with smaller tidal volumes and with larger mask deadspace. We also found that several breaths were required for equilibration of FAO2 during each trial, supporting recommendations that several breaths should be given on commencement of artificial ventilation during cardiopulmonary resuscitation.
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Affiliation(s)
- J M Stahl
- Department of Anaesthetics, St. Vincent's Hospital, Sydney, New South Wales, Australia
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32
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Stahl JM, Ellen P. Performance of rats on the Maier three-table task following septal lesions occurring 24 hours after birth. J Comp Physiol Psychol 1979; 93:1145-53. [PMID: 521524 DOI: 10.1037/h0077639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The purpose of this study was to determine whether behavioral sparing would be demonstrated when septal lesions occurred prior to the age at which the tested behavior first appears in normal rats. Rats given septal lesions at 1 day or 7 days after birth performed at approximately chance on the Maier three-table task when tested at 90 days of age. Rats that had control electrode insertions at the same ages performed at a level similar to normal animals. Animals given septal lesions at either age explored significantly more than did control animals. Results are discussed in terms of the constancy over time of the septal contribution to performance on the three-table task and the involvement of the septum and hippocampus in the processing of spatial information.
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Abstract
Two experiments are reported describing the influence of neonatal septal lesions on responding of rats trained on a differential-reinforcement-of-low-rate (DRL) schedule in adulthood. Rats given septal lesions at 1 day or at 7 days after birth emitted a significantly higher number of responses and earned fewer reinforcements than did animals given control electrode insertions. Thus, the inefficient performance on the DRL schedule, often observed after septal lesions in adulthood, does not depend upon the age of the animal at the time of the lesion. Furthermore, operant training given at an early age (25-45 days) to animals with neonatal septal damage did not facilitate performance when the animals were retrained in adulthood. In short, septal lesions at any age lead to permanent impairments of performance on a DRL 20-sec reinforcement schedule.
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Ellen P, Aitken WC, Sims T, Stahl JM. Cholinergic blockade, septal lesions, and DRL performance in the rat. J Comp Physiol Psychol 1975; 89:409-20. [PMID: 1194448 DOI: 10.1037/h0077042] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Four experiments describing the effects of cholinergic blockade produced by systemic injection of either atropine sulfate or atropine methyl nitrate on the differential reinforcement of low rate (DRL) responding of rats are reported. It was shown that atropine sulfate injected either chronically or at high dosage suppressed DRL responding. Injected acutely, atropine sulfate produced disinhibitory effects. When atropine was injected either chronically or acutely into animals with septal lesions, there was suppression of responding. It was suggested that the specific behavioral outcome resulting from cholinergic blockade depends on the balance resulting from the competing peripheral and central effects of such blockade.
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