In silico evaluation and feasibility of near margin-less head and neck daily adaptive radiotherapy

OBJECTIVE

We explore the potential dosimetric benefits of reducing treatment volumes through daily adaptive radiation therapy for head and neck cancer (HNC) patients using the Ethos system/Intelligent Optimizer Engine (IOE). We hypothesize reducing treatment volumes afforded by daily adaption will significantly reduce the dose to adjacent organs at risk. We also explore the capability of the Ethos IOE to accommodate this highly conformal approach in HNC radiation therapy.

METHODS

Ten HNC patients from a phase II trial were chosen, and their cone-beam CT (CBCT) scans were uploaded to the adaptive RT (ART) emulator. A new initial reference plan was generated using both a 1 mm and 5 mm planning target volume (PTV) expansion. Daily adaptive ART plans (1 mm) were simulated from the clinical CBCT taken every fifth fraction. Additionally, using physician-modified ART contours the larger 5 mm plan was recalculated on this recontoured on daily anatomy. Changes in target and OAR contours were measured using Dice coefficients as a surrogate of clinician effort. PTV coverage and organ-at-risk (OAR) doses were statistically compared, and the robustness of each ART plan was evaluated at fractions 5 and 35 to observe if OAR doses were within 3 Gy of pre-plan.

RESULTS

This study involved six patients with oropharynx and four with larynx cancer, totaling 70 adaptive fractions. The primary and nodal gross tumor volumes (GTV) required the most adjustments, with median Dice scores of 0.88 (range: 0.80-0.93) and 0.83 (range: 0.66-0.91), respectively. For the 5th and 35th fraction plans, 80 % of structures met robustness criteria (quartile 1-3: 67-100 % and 70-90 %). Adaptive planning improved median PTV V100% coverage for doses of 70 Gy (96 % vs. 95.6 %), 66.5 Gy (98.5 % vs. 76.5 %), and 63 Gy (98.9 % vs. 74.9 %) (p < 0.03). Implementing ART with total volume reduction yielded median dose reductions of 7-12 Gy to key organs-at-risk (OARs) like submandibular glands, parotids, oral cavity, and constrictors (p < 0.05).

CONCLUSIONS

The IOE enables feasible daily ART treatments with reduced margins while enhancing target coverage and reducing OAR doses for HNC patients. A phase II trial recently finished accrual and forthcoming analysis will determine if these dosimetric improvements correlate with improved patient-reported outcomes.

Early Experience of Online Adaptive Radiation Therapy for Definitive Radiation of Patients With Head and Neck Cancer

Purpose

The advent of cone beam computed tomography-based online adaptive radiation therapy (oART) has dramatically reduced the barriers of adaptation. We present the first prospective oART experience data in radiation of head and neck cancers (HNC).

Methods and Materials

Patients with HNC receiving definitive standard fractionation (chemo)radiation who underwent at least 1 oART session were enrolled in a prospective registry study. The frequency of adaptations was at the discretion of the treating physician. Physicians were given the option of delivering 1 of 2 plans during adaptation: the original radiation plan transposed onto the cone beam computed tomography with adapted contours (scheduled), and a new adapted plan generated from the updated contours (adapted). A paired t test was used to compare the mean doses between scheduled and adapted plans.

Results

Twenty-one patients (15 oropharynx, 4 larynx/hypopharynx, 2 other) underwent 43 adaptation sessions (median, 2). The median ART process time was 23 minutes, median physician time at the console was 27 minutes, and median patient time in the vault was 43.5 minutes. The adapted plan was chosen 93% of the time. The mean volume in each planned target volume (PTV) receiving 100% of the prescription dose for the scheduled versus adapted plan for high-risk PTVs was 87.8% versus 95% (P < .01), intermediate-risk PTVs was 87.3% versus 97.9% (P < .01), and low-risk PTVs was 94% versus 97.8% (P < .01), respectively. The mean hotspot was also lower with adaptation: 108.8% versus 106.4% (P < .01). All but 1 organ at risk (11/12) saw a decrease in their dose with the adapted plans, with the mean ipsilateral parotid (P = .013), mean larynx (P < .01), maximum point spinal cord (P < .01), and maximum point brain stem (P = .035) reaching statistical significance.

Conclusions

Online ART is feasible for HNC, with significant improvement in target coverage and homogeneity and a modest decrease in doses to several organs at risk.

Evaluating machine learning enhanced intelligent-optimization-engine (IOE) performance for ethos head-and-neck (HN) plan generation

PURPOSE

Varian Ethos utilizes novel intelligent-optimization-engine (IOE) designed to automate the planning. However, this introduced a black box approach to plan optimization and challenge for planners to improve plan quality. This study aims to evaluate machine-learning-guided initial reference plan generation approaches for head & neck (H&N) adaptive radiotherapy (ART).

METHODS

Twenty previously treated patients treated on C-arm/Ring-mounted were retroactively re-planned in the Ethos planning system using a fixed 18-beam intensity-modulated radiotherapy (IMRT) template. Clinical goals for IOE input were generated using (1) in-house deep-learning 3D-dose predictor (AI-Guided) (2) commercial knowledge-based planning (KBP) model with universal RTOG-based population criteria (KBP-RTOG) and (3) an RTOG-based constraint template only (RTOG) for in-depth analysis of IOE sensitivity. Similar training data was utilized for both models. Plans were optimized until their respective criteria were achieved or DVH-estimation band was satisfied. Plans were normalized such that the highest PTV dose level received 95% coverage. Target coverage, high-impact organs-at-risk (OAR) and plan deliverability was assessed in comparison to clinical (benchmark) plans. Statistical significance was evaluated using a paired two-tailed student t-test.

RESULTS

AI-guided plans were superior to both KBP-RTOG and RTOG-only plans with respect to clinical benchmark cases. Overall, OAR doses were comparable or improved with AI-guided plans versus benchmark, while they increased with KBP-RTOG and RTOG plans. However, all plans generally satisfied the RTOG criteria. Heterogeneity Index (HI) was on average <1.07 for all plans. Average modulation factor was 12.2 ± 1.9 (p = n.s), 13.1 ± 1.4 (p = <0.001), 11.5 ± 1.3 (p = n.s.) and 12.2 ± 1.9 for KBP-RTOG, AI-Guided, RTOG and benchmark plans, respectively.

CONCLUSION

AI-guided plans were the highest quality. Both KBP-enabled and RTOG-only plans are feasible approaches as clinics adopt ART workflows. Similar to constrained optimization, the IOE is sensitive to clinical input goals and we recommend comparable input to an institution's planning directive dosimetric criteria.

Artificial Intelligence Guided Physician Directive Improves Head and Neck Planning Quality and Practice Uniformity: A Prospective Study

•AI dose predictor was fully integrated with treatment planning system and used as a physicain decision support tool to improve uniformity of practice.•Model was trained based on our standard of practice, but implemented at the time of expansion with 3 new physicians join the practice.•Phase 1 retrospective evaluation demonstrated the non-uniform practice among 3 MDs and only 52.9% frequency planner can achieve physicians' directives.•Significant improvement in practice uniformity of practice was observed after utilizing AI as DST and 80.4% frequency clinical plan can achieve AI-guided physician directives.

Paid Sick Leave and Sickness Benefits for employees’ economic and job security: A Scoping Review

 

In health emergencies, such as in the COVID-19 pandemic, the need to expand or introduce the Paid sick leave(PSL) and Sickness benefits(SB) increases. They are key components of the universal health coverage(UHC) and active labor market policies(ALMPs) that enable workers to take care of their health and guarantee return-to-work after recovery. This study examines effects those policies in achieving economic stability and job security of covered workers through a scoping review. Studies were selected using the search terms ‘paid sick leave', ‘sickness benefits', ‘paid sick day', and ‘earned sick leave’ in PubMed and Web of Science. Our search conducted on 6th April 2021 yielded 1,030 articles, of which 22 articles were included in the review. All articles were analyzed by the 4 sub-groups(employees, families, employers, and government) and we investigated indicators of socio-economic impacts on their lives. Articles are largely PSL(90.9%)-focused. PSL guarantees not only workers’ job security by securing employment agreement, but also their income security by promising part of wages enough to afford healthcare and living expenses during the medical treatment and recovery. Additionally, PSL attenuates employers’ financial risk, as it reduces presenteeism while increasing the return-to-work rate. Moreover, PSL and SB reduce the total healthcare and social security expenditures of the government. To sum up, PSL and SB guarantee health and labor rights by ensuring income and job security to employees while assuring financial stability to both employers, and the government. However, as the previous studies paid less attention on the equity of these impacts at the system levels, future research should more focus on the dimension.

Key messages

• PSL and SB guarantee health and labour rights by ensuring income and job security for employees, while assuring financial stability for both employers and the government.

• The previous studies that examined the effects of PSL and SB paid less attention on the equity of ensuring income and employment security, therefore future studies should focus more on this dimension.

A Sick Benefit Scheme Reduces Unmet Healthcare Needs: An Natural Experiment in Seoul

 

South Korea experiences four times more unmet healthcare needs than OECD countries (11.6% and 2.6% respectively). Unmet healthcare needs are caused by the double burden of direct and indirect costs including income loss, and OECD countries operate a sickness benefit scheme to resolve sudden loss of pay. Seoul introduced the first sickness benefit system, Seoul-Type Paid Sick Leave Support (hereinafter Seoul Sick Leave), for self-employed national healthcare insurance subscribers to reduce the rate of unmet healthcare needs. By comparing the amount of increasing medical expenses between the beneficiary and non-beneficiary before (2018) and after (2019-2020) the introduction of the system, the study was intended to confirm the reduced unmet healthcare needs. This study used data from the National Health Information Database (NHID) and the difference in differences (DID) analytic framework. 96 and 121 patients were included in benefit and non-benefit cohorts, respectively. As a result, the beneficiary group’s expenses were smaller than those of the non-beneficiary group (coef.=-1.24, p = 0.026). However, the beneficiary group had a greater amount of increase in hospitalization expenses before and after the introduction than the non-beneficiary group did (coef.=1.66, p = 0.005). Our finding showed that the Seoul Sick Leave helped the precarious workers as they were able to use inpatient services when they needed. If it is to be scaled up to the national level, it should be applied all people to enhance universal health insurance in Korea.

Key messages

• Identified the effectiveness of the first sickness benefit system as it helped the precarious workers as they were able to use inpatient services when they needed.

• By financially supporting them, the Seoul Sick Leave support can achieve health promotion through early detection and treatment.

Survival and disease progression following solitary locoregional recurrence after head and neck radiotherapy

PURPOSE

The management of solitary locoregional recurrence (sLRR) of head and neck squamous cell carcinoma (HNSCC) previously treated with radiotherapy (RT) is challenging. We aimed to identify characteristics associated with improved outcome.

METHODS

We identified patients treated with non-sinus, mucosal HNSCC who initially received IMRT. We characterized overall survival (OS) and locoregional control (LRC). Multivariable analysis (MVA) on survival and patterns-of-failure were performed using Cox and Fine-Gray competing risks analysis.

RESULTS

We identified 90 patients with available follow-up. In total, 67 (74%) patients received curative-intent salvage, while 23 (26%) received palliative care. On MVA, significantly improved OS and LRC were associated with lower initial N-classification and use of salvage total laryngectomy (TL) or neck dissection (ND).

CONCLUSION

A nontrivial number of patients with sLRR cannot undergo salvage. Among patients treated with curative intent, TL or ND were clearly associated with improved OS and LRC.

Registration-guided deep learning image segmentation for cone beam CT-based online adaptive radiotherapy

PURPOSE

Adaptive radiotherapy (ART), especially online ART, effectively accounts for positioning errors and anatomical changes. One key component of online ART process is accurately and efficiently delineating organs at risk (OARs) and targets on online images, such as Cone Beam Computed Tomography (CBCT). Direct application of deep learning (DL)-based segmentation to CBCT images suffered from issues such as low image quality and limited available contour labels for training. To overcome these obstacles to online CBCT segmentation, we propose a registration-guided DL (RgDL) segmentation framework that integrates image registration algorithms and DL segmentation models.

METHODS

The RgDL framework is composed of two components: image registration and registration-guided DL segmentation. The image registration algorithm transforms / deforms planning contours, which were subsequently used as guidance by the DL model to obtain accurate final segmentations. We had two implementations of the proposed framework-Rig-RgDL (Rig for rigid body) and Def-RgDL (Def for deformable)-with rigid body (RB) registration or deformable image registration (DIR) as the registration algorithm, respectively, and U-Net as the DL model architecture. The two implementations of RgDL framework were trained and evaluated on seven OARs in an institutional clinical Head and Neck (HN) dataset.

RESULTS

Compared to the baseline approaches using the registration or the DL alone, RgDLs achieved more accurate segmentation, as measured by higher mean Dice similarity coefficients (DSC) and other distance-based metrics. Rig-RgDL achieved a DSC of 84.5% on seven OARs on average, higher than RB or DL alone by 4.5% and 4.7%. The average DSC of Def-RgDL was 86.5%, higher than DIR or DL alone by 2.4% and 6.7%. The inference time required by the DL model component to generate final segmentations of seven OARs was less than one second in RgDL. By examining the contours from RgDLs and DL case by case, we found that RgDL was less susceptible to image artifacts. We also studied how the performances of RgDL and DL vary with the size of the training dataset. The DSC of DL dropped by 12.1% as the number of training data decreased from 22 to 5, while RgDL only dropped by 3.4%.

CONCLUSION

By incorporating the patient-specific registration guidance to a population-based DL segmentation model, RgDL framework overcame the obstacles associated with online CBCT segmentation, including low image quality and insufficient training data, and achieved better segmentation accuracy than baseline methods. The resulting segmentation accuracy and efficiency show promise for applying this RgDL framework for online ART. This article is protected by copyright. All rights reserved.

Prognostic impact of matted lymphadenopathy in patients with oropharyngeal squamous cell carcinoma treated with definitive chemoradiotherapy

OBJECTIVE

To determine whether cervical matted lymphadenopathy (ML) is associated with outcomes in patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with definitive chemoradiotherapy (CRT).

MATERIALS AND METHODS

OPSCC patients treated at our institution with CRT were included (n = 417). ML was defined by three adjacent nodes without an intervening fat plane. Patients were stratified into favorable OPSCC (p16 + with ≤ 10 pack-years smoking history) or unfavorable OPSCC (p16- and/or > 10 pack years). Primary outcomes were overall survival (OS) and progression-free survival (PFS) and the cumulative incidences of regional recurrence (RR) and distant metastasis (DM).

RESULTS

The median follow-up time for the surviving cohort was 49.9 months. In favorable OPSCC (n = 220), there were no significant associations between ML and any outcome. In unfavorable OPSCC (n = 197), ML had a significant negative impact on OS and PFS, with 3-year OS for patients without and with matted nodes at 74% and 56% (HR, 1.61, 95% CI 1.01-2.58). On multivariable Cox regression, patients with ML experienced significantly worsened OS (HR 1.65, 95% CI 1.03-2.65) and PFS (HR 1.94, 95% CI 1.28-2.93). The cumulative incidence of DM was also higher with ML (31% vs. 9%, adjusted HR 3.3, 95% CI 1.71-6.48).

CONCLUSION

ML carries no prognostic importance in patients with favorable OPSCC. However, ML portends significantly worse outcomes in individuals with HPV-negative disease or a significant smoking history. Thus, ML may help risk-stratify this latter population for treatment intensification, but does not seem to be a contraindication for treatment de-escalation in the former.

NCCN Guidelines® Insights: Older Adult Oncology, Version 1.2021

The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults, including screening and comprehensive geriatric assessment (CGA), assessing the risks and benefits of treatment, preventing or decreasing complications from therapy, and managing patients deemed to be at high risk for treatment-related toxicity. CGA is a multidisciplinary, in-depth evaluation that assesses the objective health of the older adult while evaluating multiple domains, which may affect cancer prognosis and treatment choices. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines providing specific practical framework for the use of CGA when evaluating older adults with cancer.

Robotic prostatectomy after abandoned open radical prostatectomy—Technical aspects and outcomes

Objective

To describe the technical aspects and outcomes of robotic‐assisted radical prostatectomy (RARP) following abandoned open radical prostatectomy (ORP).

Patients and Methods

A retrospective review was performed of patients who underwent RARP following abandonment of ORP between 2016 and 2020. RARP was undertaken by two highly experienced robotic surgeons. Analysis of patient and operative characteristics, outcomes, and reasons for abandonment of ORP were described.

Results

Six patients were included for analysis with a median age of 63.5 years [50.3‐67.5]. The median body mass index (BMI) was 34.7 [27.8‐36.2]. All patients had intermediate‐risk prostate cancer. Small prostate and deep pelvis were given as reasons for abandoning ORP in five cases (83.3%), with four of these also attributing increased BMI as a factor. Extensive mesh from previous bilateral inguinal hernia repair was cited as the reason for abandonment in the remaining patient. One patient had commenced androgen deprivation therapy following abandoned ORP. Extensive retropubic adhesions were noted at the time of RARP in five of six patients, with intraoperative complication of small bladder lacerations encountered in the patient with prior mesh hernia repair. The median time from abandoned ORP to RARP was 128 days [40‐216]. Median operating time was 160 minutes [139‐190] and estimated blood loss was 225 mL [138‐375]. Negative margins were obtained in four of six cases, with further salvage treatment being required in one case at a median follow‐up duration of 10.5 months [6.5‐25.3].

Conclusion

Abandonment of ORP is an uncommonly reported event, however, in this small case series, we demonstrate that, in the hands of experienced surgeons, RARP is a safe and technically feasible alternative in such cases. Increased BMI, small prostate size and pelvic anatomical constraints appear to be common catalysts for abandonment of open surgery in this cohort. Identifying these high‐risk patients early and considering referral to robotic centers may be preferred.

Abstract 410: Quantification and downstream analysis of circulating tumor cells isolated using CapioCyteTM liquid biopsy

Background: Circulating tumor cells (CTCs) have great potential as biomarkers for the diagnosis and prognosis of many cancers. The CapioCyteTM chip isolates live CTCs through a unique combination of biomimetic cell rolling and nanoparticle-mediated multivalent immunorecognition. Recently-published work reported the highly sensitive and specific CTC capture from 24 patients in a pilot study [Myung et al., Clinical Cancer Research 2018, 24(11):2439-2547]. Here, we report results from additional cohorts of patients and demonstrate downstream analysis of captured CTCs.

Methods: Peripheral blood samples were collected from patients undergoing radiotherapy (RT) (n=12; oligometastic n = 5, head and neck cancer n = 1, non small cell lung cancer n = 2, prostate cancer n = 3, cervical cancer n = 1) or immunotherapy (n=4). Samples were processed the next day by CapioCyteTM chips designed for the immunoisolation cells expressing epithelial cell adhesion molecule (EpCAM), human epidermal growth factor-2 (HER-2), and epidermal growth factor receptor (EGFR). Captured CTCs were identified by immunocytochemistry as containing round nuclei, positive expression of cytokeratin, and negative expression of CD45. Select samples were recovered from the capture surface and submitted for single cell gene expression assays (RNASeq) using 10X Genomics Chromium barcoding and Illumina next-generation sequencing.

Results: Immunocytochemical staining identified CTCs in all pre-treatment blood samples from patients undergoing RT (mean 95 CTC/ml whole blood, SE 54, range 4-680) and immunotherapy (mean 70 CTC/ml whole blood, SE 16, range 39-104). CTC counts decreased with time points collected during and post-treatment, consistent with other measures of treatment progress. Single cell RNASeq confirmed the presence of tumor-derived cells in select samples and, importantly, demonstrated the ability to conduct downstream analysis of CTCs isolated on the CapioCyteTM chip.

Conclusions: The CapioCyteTM chip effectively captures CTCs for quantification and downstream analysis requiring viable cells such as RNASeq. The liquid biopsy technology has great potential to contribute to diagnosis and personalized treatment of cancer.

Citation Format: Michael J. Poellmann, Jiyoon Bu, Dominic Moon, Kyle Wagner, Andrew Z. Wang, Seungpyo Hong. Quantification and downstream analysis of circulating tumor cells isolated using CapioCyteTM liquid biopsy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 410.

Targeted radiosensitization with PARP1 inhibition: optimization of therapy and identification of biomarkers of response in breast cancer

Sustained locoregional control of breast cancer is a significant issue for certain patients. Inhibition of PARP1 is a promising strategy for radiosensitization (RS). We sought to optimize therapy with PARP1 inhibition and radiation (RT) by establishing the most effective treatment schedule, degree of PARP1-mediated RS, and identify early biomarkers predictive of efficacy in breast cancer models. Using clonogenic survival assays, we assessed intrinsic radiosensitivity and RS induced by PARP1 inhibition in breast cancer cell lines. Potential biomarkers of response were evaluated using western blotting, flow cytometry, and immunofluorescence with validation in vivo using tumor xenograft experiments. Across a panel of BC and normal breast epithelial cell lines, the PARP1 inhibitor ABT-888 preferentially radiosensitizes breast cancer (vs. normal) cells with enhancement ratios (EnhR) up to 2.3 independent of intrinsic BC subtype or BRCA mutational status. Concurrent and adjuvant therapy resulted in the highest EnhR of all schedules tested. The degree of RS did not correlate with pretreatment markers of PARP1 activity, DNA damage/repair, or cell cycle distribution. Increases in PARP1 activity 24 h after RT were associated with sensitivity after combination treatment. Findings were confirmed in breast cancer xenograft models. Our study demonstrates that PARP1 inhibition improves the therapeutic index of RT independent of BC subtype or BRCA1 mutational status and that PARP1 activity may serve as a clinically relevant biomarker of response. These studies have led to a clinical trial (TBCRC024) incorporating intratreatment biomarker analyses of PARP1 inhibitors and RT in breast cancer patients.

Top-up operation at Pohang Light Source-II

After three years of upgrading work, PLS-II (S. Shin, Commissioning of the PLS-II, JINST, January 2013) is now successfully operating. The top-up operation of the 3 GeV linear accelerator had to be delayed because of some challenges encountered, and PLS-II was run in decay mode at the beginning in March 2012. The main difficulties encountered in the top-up operation of PLS-II are different levels between the linear accelerator and the storage ring, the 14 narrow gap in-vacuum undulators in operation, and the full energy injection by 3 GeV linear accelerator. Large vertical emittance and energy jitter of the linac were the major obstacles that called for careful control of injected beam to reduce beam loss in the storage ring during injection. The following measures were taken to resolve these problems: (1) The high resolution Libera BPM (see http://www.i-tech.si) was implemented to measure the beam trajectory and energy. (2) Three slit systems were installed to filter the beam edge. (3) De-Qing circuit was applied to the modulator system to improve the energy stability of injected beam. As a result, the radiation by beam loss during injection is reduced drastically, and the top-up mode has been successfully operating since 19th March 2013. In this paper, we describe the experimental results of the PLS-II top-up operation and the improvement plan.

Application of a computerized language lateralization index from FMRI by a group of clinical neuroradiologists

BACKGROUND AND PURPOSE

Deriving accurate language lateralization from fMRI studies in the clinical context can be difficult, with 10%-20% incorrect conclusions. Most interpretations are qualitative, performed by neuroimaging experts. Quantitative lateralization has been widely described but with little implementation in the clinical setting and is disadvantaged by the use of arbitrary threshold techniques. We investigated the application and utility of a nonthreshold CLI, in a clinical setting, as applied by a group of practicing neuroradiologists.

MATERIALS AND METHODS

Twenty-two patients with known language lateralization (11 left and 11 nonleft dominant) had their images reviewed by 8 neuroradiologists in 2 settings, all randomized, once by using a CLI and once without using a CLI. For each review, neuroradiologists recorded their impressions of lateralization for each language sequence, the overall lateralization conclusion, their impression of scan quality and noise, and the subjective confidence in their conclusion.

RESULTS

The inter-rater κ for lateralization was 0.64, which increased to 0.70 with the use of CLI. The group accuracy of overall lateralization was 78%, which increased to 81% with the use of a CLI. Using a CLI removed 2 instances of significant errors, with a neuroradiologist's impression of left lateralization in a patient with known right lateralization. Using a CLI had no effect on examinations with conclusions formed with either high confidence or no confidence.

CONCLUSIONS

Although the overall clinical benefit of a CLI is modest, the most significant impact is to reduce the most harmful misclassification errors, particularly in fMRI examinations that are suboptimal.

Effect of a prescan patient-radiologist encounter on functional MR image quality

BACKGROUND AND PURPOSE

A substantial number of clinical fMRI examinations inadequately assess language localization or lateralization, usually due to patient movement and suboptimal participation. We hypothesized that a prescan interview of the patient by the radiologist would reduce the fraction of nondiagnostic scans.

MATERIALS AND METHODS

A single noise score for each acquisition was produced from time-series data on the basis of a weighted sum of 22 factors. Scores were recorded as the following quartiles: 0-5 = excellent, 5-10 = adequate, 10-15= marginal, and >15 = unacceptable. This measure was evaluated for 202 consecutive fMRI patients: 96 without and 106 with a physician prescan interview. The data were analyzed to compute the fraction of all nondiagnostic sequences and entire studies and were compared between the 2 groups. Image-noise characteristics included the SDs of linear and angular displacements of the head and the number of time-series outliers caused by focal motion.

RESULTS

Of 999 sequences acquired, 539 had a prescan interview. The mean noise score significantly decreased for both individual sequence (from 7.9 to 6.3, P = <.001) and study-based (from 7.7 to 6.2, P = .05) methods. The fraction of sequences or studies scored as unacceptable decreased for sequence-based (from 15.2% to 10.9%, P = .04) and study-based (from 9.4% to 1.9%, P = .02) analyses. SDs of head motion decreased for linear (by 12%-14%, P < .01) and angular displacement (by 38%-48%, P < .001). The number of time-series spikes decreased by 10% (P = .004).

CONCLUSIONS

We report that a prescan physician-patient interview modestly but significantly reduces fMRI noise scores. These results support the newly added billable costs of professional intervention before fMRI scans.

Selective Mastectomy in the Management of Locally Advanced Breast Cancer

PURPOSE

To evaluate local control for patients with locally advanced noninflammatory breast cancer (LABC) managed by selective mastectomy.

METHODS AND MATERIALS

Between 1979 and 1996, 176 patients with LABC were prospectively managed by chemotherapy (CT)-irradiation (RT)-CT without routine mastectomy. All surviving patients were followed for a minimum of 5 years.

RESULTS

A total of 132 patients (75%) had a T4 tumor and 22 (12.5%) supraclavicular nodal disease. The clinical complete response rate was 91% (160/176), which included 13 patients who underwent mastectomy and 2 an iridium wire implant. The first site of failure was local for 43 patients (breast +/- axilla for 38); 27 of these patients underwent salvage mastectomy and 11 did not for an overall mastectomy rate of 23% (40/176). If all 176 patients had undergone routine mastectomy (136 extra mastectomies), 11 additional patients may have avoided an unsalvageable first local relapse. The others would have either have not had a local relapse or would have suffered local relapse after distant disease. No tumor or treatment related factor was found to predict local disease at death. Median disease-free and overall survival for all patients was 26 and 52 months, respectively.

CONCLUSIONS

Selective mastectomy in LABC may not jeopardize local control or survival.

The use of complementary and alternative medicine in patients with terminal cancer in Korea: Nationwide cross-sectional study

19534

Background: Although the use of complementary and alternative medicine(CAM) is widespread among patients with chronic diseases including cancer, little is known about CAM use in terminal cancer patients. Methods: This study included 4,042 families of cancer patients who died at 17 hospitals in Korea between January and December 2004. We conducted with telephone survey to decedents’ families. The response rate was 41.1%. The questionnaire included whether cancer patients had used CAM during last one year before death, type of modality, motivation for use, attitudes to CAM, and consultation with doctors. Results: CAM use of cancer patients was reported by 36.3% (604 of 1,662) and the average rate of CAM cost was 32% of total medical costs during one year before patient’s death. CAM use was more likely to death at hospitals (adjusted Odds Ratio: 1.35, 95% Confidential Interval: 1.15–1.58), residence in rural (aOR:1.26, 95%CI:1.08–1.47), need consultations about care (aOR:1.65, 95%CI:1.30–2.09) and religious support (aOR:1.3, 95% CI:1.11–1.53), diagnosis except liver/gallbladder cancer (aOR:0.67, 95%CI:0.55–0.81), and longer disease period (aOR:1.85, 95% CI:1.5–2.2). Use was greatest for mushrooms (41.6%), vegetable juice (25.6%), ginseng (21.8%) and Chinese medicine (16.4%). The motivation for CAM use was the recommendations from family members or friends (83.5%) and internet or advertisement (16.1%) but physicians’ recommendation or education (1.4%) was rare. The 37.4% of families of CAM-used patients were satisfied with CAM because of but feeling better or comfortable (79.3%), not cure (5.4%). And otherwise, the 62.1% of them were unsatisfied with CAM because of no effect (87.3%). Only 41.7% CAM users consulted with their physician. Conclusions: This study revealed a high prevalence of CAM use among terminal cancer patients without recommendation from doctors. Medical staffs should evaluate patients’ CAM use and inform accurately about CAM to terminal cancer patients and family for quality of care improvement.

No significant financial relationships to disclose.

[18F]fluorothymidine (FLT) PET after 3 days of gefitinib treatment and tumor response in non-small cell lung cancer (NSCLC)

13031

Background: FLT has been developed as a PET tracer for imaging tumor proliferation. We evaluated whether FLT-PET could predict tumor response only after 3 days of gefitinib treatment. Methods: Nonsmokers with adenocarcinoma of the lung were eligible for this study. FLT-PET was performed at 1 day before and 3 days after the start of gefitinib (250 mg/d) therapy. The maximum standardized uptake value (SUVmax) of the main lung mass was measured, and changes in tumor SUVmax were calculated. After 6 weeks of therapy, response was assessed by chest CT according to WHO criteria. The cutoff value predicting subsequent CT response was obtained by receiver operating characteristic curve analysis. Results: Between Jun. 2005 and Nov. 2005, 22 patients were enrolled. CT response was partial response in 12 (54%), stable disease in 5 (23%), and progressive disease in 5 (23%). As early as 3 days after the initiation of therapy, significant difference in % changes of tumor SUVmax on FLT-PET was observed between responders and nonresponders (−32% v −2.3%, P = .002) ( Table ). When a reduction of tumor SUVmax ≥ 20% was used as a cutoff value for FLT-PET response, CT response could be predicted with positive and negative predictive values of 100% and 83%, respectively. Time to progression was significantly longer in FLT-PET responders than nonresponders (median 5.1 v 1.4 months, P = .011). Conclusions: Using FLT-PET obtained on days 0 and 3 of gefitinib therapy, the response could be early predicted in patients with NSCLC.

[Table: see text]

No significant financial relationships to disclose.

The impact of prostate size in laparoscopic radical prostatectomy

OBJECTIVES

Large prostates can be challenging to remove during open or laparoscopic radical prostatectomy (LRP). Our objective was to critically analyse the impact of prostate volume in LRP.

METHODS

400 cases of LRP were performed. Three hundred and fourteen patients had a small prostate (weight < 75 g) and 86 patients had a large prostate (weight > or = 75 g) on final histology. The following outcomes were assessed: operative time; estimated blood loss (EBL); transfusion rate; length of hospital stay (LOS); length of catheterisation; perioperative and postoperative complications (including incontinence and erectile dysfunction); surgical margin status; and early biochemical recurrence rates.

RESULTS

Patients' age, PSA, Gleason sum and clinical stage were all similar. Larger prostates were associated with a 14 minutes longer mean operating time (p < 0.001), but fewer positive surgical margins (p = 0.01). Blood loss, blood transfusion rate, length of hospital stay, length of catheterisation and complication rate were all similar in both groups.

CONCLUSIONS

Prostate size should not be a factor determining a patient's suitability for LRP. Further follow-up is needed to assess the effect of prostate size on long-term functional and oncological results.

The Impact of Prostate Size in Laparoscopic Radical Prostatectomy

OBJECTIVES

Large prostates can be challenging to remove during open or laparoscopic radical prostatectomy (LRP). Our objective was to critically analyse the impact of prostate volume in LRP.

METHODS

400 cases of LRP were performed. Three hundred and fourteen patients had a small prostate (weight < 75 g) and 86 patients had a large prostate (weight > or = 75 g) on final histology. The following outcomes were assessed: operative time; estimated blood loss (EBL); transfusion rate; length of hospital stay (LOS); length of catheterisation; perioperative and postoperative complications (including incontinence and erectile dysfunction); surgical margin status; and early biochemical recurrence rates.

RESULTS

Patients' age, PSA, Gleason sum and clinical stage were all similar. Larger prostates were associated with a 14 minutes longer mean operating time (p < 0.001), but fewer positive surgical margins (p = 0.01). Blood loss, blood transfusion rate, length of hospital stay, length of catheterisation and complication rate were all similar in both groups.

CONCLUSIONS

Prostate size should not be a factor determining a patient's suitability for LRP. Further follow-up is needed to assess the effect of prostate size on long-term functional and oncological results.

Determinants of outcome in melanoma patients with cerebral metastases

PURPOSE

To analyze prognostic factors, effects of treatment, and survival for patients with cerebral metastases from melanoma.

PATIENTS AND METHODS

All melanoma patients with cerebral metastases treated at the Sydney Melanoma Unit between 1952 and 2000 were identified. From 1985 to 2000, patients were diagnosed and treated using consistent modern techniques and this cohort was analyzed in detail. Multivariate analysis of prognostic factors for survival was performed.

RESULTS

A total of 1137 patients with cerebral metastases were identified; 686 were treated between 1985 and 2000. For these 686 patients, the median time from primary diagnosis to cerebral metastasis was 3.1 years (range, 0 to 41 years). A total of 646 patients (94%) have died as a result of melanoma. The median survival from the time of diagnosis of cerebral metastasis was 4.1 months (range, 0 to 17.2 years). Treatment was as follows: surgery and postoperative radiotherapy, 158 patients; surgery alone, 47 patients; radiotherapy alone, 236 patients; and supportive care alone, 210 patients. Median survival according to treatment received for these four groups was 8.9, 8.7, 3.4, and 2.1 months, respectively; the differences between surgery and nonsurgery groups were statistically significant. On multivariate analysis, significant factors associated with improved survival were surgical treatment (P <.0001), no concurrent extracerebral metastases (P <.0001), younger age (P =.0007), and longer disease-free interval (P =.036). Prognostic factors analysis confirmed the important influence of patient selection on treatment received.

CONCLUSION

This large series documents the characteristics of patients who developed cerebral metastases from melanoma. Median survival was dependent on treatment, which in turn was dependent on patient selection.