Radiation Oncology Ransomware Attack Response Risk Analysis Using Failure Modes and Effects Analysis

PURPOSE

There have been numerous significant ransomware attacks impacting Radiation Oncology in the past 5 years. Research into ransomware attack response in Radiation Oncology has consisted of case reports and descriptive articles and has lacked quantitative studies. The purpose of this work was to identify the significant safety risks to patients being treated with radiation therapy during a ransomware attack scenario, using Failure Modes and Effects Analysis.

METHODS AND MATERIALS

A multi-institutional and multidisciplinary team conducted a Failure Modes and Effects Analysis by developing process maps and using Risk Priority Number (RPN) scores to quantify the increased likelihood of incidents in a ransomware attack scenario. The situation that was simulated was a ransomware attack that had removed the capability to access the Record and Verify (R&V) system. Five situations were considered: 1) a standard treatment of a patient with and without an R&V, 2) a standard treatment of a patient for the first fraction right after the R&V capabilities are disabled, and 3) 3 situations in which a plan modification was required. RPN scores were compared with and without R&V functionality.

RESULTS

The data indicate that RPN scores increased by 71% (range, 38%-96%) when R&V functionality is disabled compared with a nonransomware attack state where R&V functionality is available. The failure modes with the highest RPN in the simulated ransomware attack state included incorrectly identifying patients on treatment, incorrectly identifying where a patient is in their course of treatment, treating the incorrect patient, and incorrectly tracking delivered fractions.

CONCLUSIONS

The presented study quantifies the increased risk of incidents when treating in a ransomware attack state, identifies key failure modes that should be prioritized when preparing for a ransomware attack, and provides data that can be used to guide future ransomware resiliency research.

Serum testosterone changes in patients treated with radiation therapy alone for prostate cancer on NRG oncology RTOG 9408

Objectives

We reviewed testosterone changes for patients who were treated with radiation therapy (RT) alone on NRG oncology RTOG 9408.

Methods and materials

Patients (T1b-T2b, prostate-specific antigen <20 ng/mL) were randomized between RT alone and RT plus 4 months of androgen ablation. Serum testosterone (ST) levels were investigated at enrollment, RT completion, and the first follow-up 3 months after RT. The Wilcoxon signed rank test was used to compare pre- and post-treatment ST levels in patients who were randomized to the RT-alone arm.

Results

Of 2028 patients enrolled, 992 patients were randomized to receive RT alone and 917 (92.4%) had baseline ST values available and completed RT. Of these 917 patients, immediate and 3-month post-RT testosterone levels were available for 447 and 373 patients, respectively. Excluding 2 patients who received hormonal therapy off protocol after RT, 447 and 371 patients, respectively, were analyzed. For all patients, the median change in ST values at completion of RT and at 3-month follow-up were −30.0 ng/dL (p5-p95; −270.0 to 162.0; P < .001) and −34.0 ng/dL (p5-p95, −228.0 to 160.0; P < .01), respectively.

Conclusion

RT for prostate cancer was associated with a median 9.2% decline in ST at completion of RT and a median 9.3% decline 3 months after RT. These changes were statistically significant.

Immediate side effects of stereotactic radiotherapy and radiosurgery

PURPOSE

Despite increased utilization of fractionated stereotactic radiation therapy (SRT) or stereotactic radiosurgery (SRS), the incidence and nature of immediate side effects (ISE) associated with these treatment techniques are not well defined. We report immediate side effects from a series of 78 patients.

MATERIALS AND METHODS

Intracranial lesions in 78 adult patients were treated with SRT or SRS, using a dedicated linear accelerator. Those lesions included 13 gliomas, 2 ependymomas, 19 metastatic tumors, 15 meningiomas, 12 acoustic neuromas, 4 pituitary adenomas, 1 optic neuroma, 1 chondrosarcoma, and 11 arteriovenous malformations (AVM). SRT was used in 51 and SRS in 27 patients. Mean target volume was 9.0 cc. Eleven patients received prior external-beam radiation therapy within 2 months before SRT/SRS. Any side effects occurring during and up to 2 weeks after the course of radiation were defined as ISE and were graded as mild, moderate, or severe. The incidence of ISE and the significance of their association with several treatment and pretreatment variables were analyzed.

RESULTS

Overall, 28 (35%) of 78 patients experienced one or more ISE. Most of the ISE (87%) were mild, and consisted of nausea (in 5), dizziness/vertigo (in 5), seizures (in 6), and new persistent headaches (in 17). Two episodes of worsening neurological deficit and 2 of orbital pain were graded as moderate. Two patients experienced severe ISE, requiring hospitalization (1 seizure and 1 worsening neurological deficit). ISE in 6 cases prompted computerized tomography of the brain, which revealed increased perilesional edema in 3 cases. The incidence of ISE by diagnosis was as follows: 46% (6 of 13) for gliomas, 50% (6 of 12) for acoustic neuromas, 36% (4 of 11) for AVM, 33% (5 of 15) for meningiomas, and 21% (4 of 19) for metastases. A higher incidence of dizziness/vertigo (4 of 12 = 33%) was seen among acoustic neuroma patients than among other patients (p< 0.01). There was no significant association of dizziness/vertigo with either a higher average and maximum brainstem dose (p = 0.74 and 0.09, respectively) or with 2-Gy equivalents of the average and maximum brainstem doses (p = 0.28 and 0.09, respectively). Higher RT dose to the margin and higher maximum RT dose were associated with a higher incidence of ISE (p = 0.05 and 0.01, respectively). However, when RT dose to the margin was converted to a 2-Gy dose-equivalent, it lost its significance as predictor of ISE (p = 0.51). Recent conventional external-beam radiation therapy, target volume, number of isocenters, collimator size, dose inhomogeneity, prescription isodose, pretreatment edema, dose of prior radiation, fraction size (2.0-7.0 Gy with SRT and 13.0-21.0 Gy with SRS), fractionation schedule, and dose to brainstem were not significantly associated with ISE. ISE occurred in 26% (8) of 31 patients taking corticosteroids prior to SRT/SRS and in 20 (42%) of 47 patients not taking them (p = 0.15).

CONCLUSION

ISE occur in one third of patients treated with SRT and SRS and are usually mild or moderate and self-limited. Dizziness/vertigo are common and unique for patients with acoustic neuromas and are not associated with higher brainstem doses. We are unable to detect a relationship between ISE and higher margin or maximum RT doses. No specific conclusion can be drawn with regard to the effect of corticosteroids, used prior to SRS/SRT, on the occurrence of ISE.

Patterns of tumor progression after radiotherapy for low-grade gliomas: analysis from the computed tomography/magnetic resonance imaging era

Postoperative radiotherapy for low-grade gliomas has been shown in retrospective series to improve survival, compared with surgery alone. To determine the proper radiotherapy treatment volume and dose, an understanding of the patterns of failure with current radiotherapy techniques is necessary. We studied 30 consecutive patients who had a pathologic diagnosis of low-grade nonpilocytic glioma treated in our department between 1975 and 1994. Before radiotherapy, 5 patients underwent biopsy, 22 had subtotal resection, and 3 had gross total excision. All had pre- and posttreatment computed tomographic (CT) or magnetic resonance imaging (MRI) scanning. Megavoltage radiotherapy was delivered to shrinking partial (22 patients) or whole-brain (8 patients) fields. Median dose was 59.4 Gy (range, 46.4-64 Gy) in 1.8- to 2-Gy fractions. Median follow-up was 44 months (3-215 months) for the cohort and 105 months for survivors. For the entire series, 5-year overall survival and relapse-free survival rates were 50% and 41%, respectively. Sixteen patients (53%) progressed at a median of 30 months. At the time of failure, 71% (5 of 7) of pathologically evaluated tumors were of high grade. Recurrence originated within the field in all patients. Higher 5-year overall survival and relapse-free survival rates were associated (p < 0.001) with preradiotherapy functional status 1 versus functional status 2 through 4 (60% vs. 0% and 55% vs. 0%, respectively). Seizure as initial presentation was favorable over other symptoms (5-year overall survival, 64% versus 14%; p = 0.057). We conclude that 1) low-grade nonpilocytic gliomas can transform to high-grade lesions after treatment with conventional radiotherapy, 2) recurrence uniformly occurs within the treatment volume, and 3) pretreatment functional status correlates prognostically with survival. The local pattern of failure suggests that radiotherapy dose escalation within conformal fields could improve results.

Emergent/urgent therapeutic irradiation in pediatric oncology: patterns of presentation, treatment, and outcome

PURPOSE

We reviewed all pediatric cases referred for emergent/urgent therapy (requiring treatment within 48 hours) to identify frequency, patterns of presentation, and efficacy of therapy. We defined five categories of emergent/urgent therapy based on irradiated site and/or signs: Group I, spinal cord compression; Group II, respiratory compromise; Group III, infradiaphagmatic distress; Group IV, intracranial signs; Group V, pain.

MATERIALS AND METHODS

From 2/1/88-3/1/ 94, 104 children with 115 problems were referred by specialists at the Children's Hospital of Philadelphia. Diagnosis, nature of the emergency, and response were examined. Responses were categorized as complete resolution, improvement or stabilization, and progression.

RESULTS

The 104 children represented 12% of referrals during the study period. The most common tumors were CNS PNET and gliomas (20%); and neuroblastoma (20%). Forty-five problems occurred with newly diagnosed tumors and 70 after progression. Ninety-one episodes were managed with radiation therapy and 24 with other modalities. Patients with spinal cord/cauda equina (n = 33) compression improved (55%) or stabilized (30%). Patients with respiratory compromise from thoracic (n = 14) or abdominal (n = 5) disease had a response rate of 72%. Eight patients in group III had a 66% response. In Group IV (n = 16), 63% had complete responses and 19% had stabilization. Group V (n = 15) patients had a complete or partial response of 93%.

CONCLUSION

Approximately 10% of children referred for radiation therapy required emergent/urgent treatment. Eighty percent of patients achieved stabilization or showed improvement in signs and symptoms, indicating that radiotherapy is a valuable and reliable component of multimodal care in such situations.