Patterns of Care and Survival Outcomes in the Treatment of Anal Melanoma

PURPOSE

Anal mucosal melanoma is an uncommon malignancy of the anal canal, with few large studies available to establish clear trends in the treatment modalities presently available. The primary goal of this study was to identify the patterns of care in the treatment of anal melanoma and secondarily to determine outcomes.

METHODS

This was a retrospective study performed utilizing the National Cancer Database (NCDB). A total of 787 patients diagnosed with anal melanoma between 2004 and 2014 were selected, of which 398 had staging information. The four treatment groups analyzed were surgical excision alone, surgical excision and radiation therapy, surgical excision and immunotherapy/chemotherapy, and radiation therapy plus minus immunotherapy/chemotherapy. Treatment was grouped by extent of disease; the Kaplan-Meier method was used to analyze overall survival and multivariate Cox proportional model was used to identify factors associated with overall survival.

RESULTS

The majority of patients presented with either node-positive (39.4%) or metastatic disease (37.4%). Patients with surgical excision and radiation therapy had the highest median survival at 32.3 months. This is in contrast with those receiving surgical excision alone (22.9 months), surgery and immunotherapy/chemotherapy (18.4 months), and radiation without surgery (5.1 months) (p < 0.0001).

CONCLUSIONS

Treatment with surgical excision was the most common initial treatment with no single modality superior over another in this rare entity.

#WomenWhoCurie: Leveraging Social Media to Promote Women in Radiation Oncology

The proportion of female trainees in radiation oncology has generally declined despite increasing numbers of female medical students; as a result, radiation oncology is among the bottom 5 specialties in terms of the percentage of female applicants. Recently, social media has been harnessed as a tool to bring recognition to underrepresented groups within medicine and other fields. Inspired by the wide-reaching social media campaign of #ILookLikeASurgeon to promote female physicians, members of the Society for Women in Radiation Oncology penned a new hashtag and launched the #WomenWhoCurie social media campaign on Marie Curie's birthday November 7th, as part of their strategy to raise public awareness. From November 6, 2018 until November 10, 2018, the #WomenWhoCurie hashtag delivered 1,135,000 impressions, including 408 photos from all over the world including United States, Spain, Canada, France, Australia, Ireland, the United Kingdom, Mexico, Japan, the Netherlands, India, Ecuador, Panama, Brazil, and Nigeria. Alongside continued gender disparity research, social media should continue to be used as a tool to engage the community and spur conversations to formulate solutions for gender inequity.

Stereotactic Body Radiation Therapy for Spinal Malignancies

Stereotactic body radiation therapy and stereotactic radiosurgery have become important treatment options for the treatment of spinal malignancies. A better understanding of dose tolerances with more conformal technology have allowed administration of higher and more ablative doses. In this review, the framework for approaching a patient with spinal metastases and primary tumors will be discussed as well as details on the delivery of this treatment.

The utilization of MGMT promoter methylation testing in United States hospitals for glioblastoma and its impact on prognosis

Multiple studies have identified O⁶-methylguanine-DNA methyltransferase (MGMT) promoter methylation status to be an important prognostic factor in glioblastoma (GBM). We used the National Cancer Data Base (NCDB) to analyze completeness of coding for MGMT as well as to compare outcomes of GBM patients treated with adjuvant chemoradiation based on MGMT promoter methylation status (positive, negative, unknown). Patients diagnosed with GBM from 2010 to 2012 who received adjuvant chemoradiation were identified. MGMT promoter methylation status was obtained. The Kaplan-Meier method was used to assess overall survival (OS) by coding status of MGMT promoter methylation (positive, negative, unknown) and Cox regression analysis was used to assess impact of covariables on OS. There were 12,725 patients who met the study criteria, of which 626 (4.9%) were MGMT+, 1,037 (8.1%) were MGMT- and 11.062 (86.9%) were coded as unknown/not coded. Treatment at academic centers was strongly associated with MGMT promoter status testing (OR 2.23, p < 0.001), as well as hospital facility within the Northeast (OR 1.55, p < 0.001). The median and 2-year OS was 20 months and 40.2% for MGMT+ compared to 15 months and 24.1% for MGMT-, respectively (p < 0.001). For those coded as MGMT unknown, median and 2-year OS was 14.6 months and 27.5%, which was significantly worse compared to MGMT+ (p < 0.001) but not compared to MGMT- (p = 0.78). On multivariable analysis, MGMT+ was strongly associated with improved OS (HR 0.74, p < 0.001). Despite convincing evidence that MGMT promoter methylation status has a strong influence on prognosis; it appears to be a highly underutilized test in United States hospitals.

Impact of Timing of Adjuvant Chemoradiation for Glioblastoma in a Large Hospital Database

BACKGROUND

Although the standard of care for glioblastoma remains maximal safe resection followed by chemoradiation, conflicting reports have emerged regarding the importance of the time interval between these 2 treatments.

OBJECTIVE

To assess whether differences in the duration between surgery and initiation of chemoradiation for glioblastoma had an impact on overall survival (OS) in a large hospital-based database.

METHODS

The National Cancer Database was queried to identify patients diagnosed with glioblastoma between 2010 and 2012 treated with surgery followed by chemoradiation. Patients who received biopsy only were excluded. The time from surgery to initiation of radiation therapy was divided into 4 equal quartiles of ≤24, 25 to 30, 31 to 37, and &gt;37 d. Patient characteristics were compared between groups using Pearson Chi Square and Fisher's Exact test. OS was analyzed via the Kaplan–Meier method and compared via the log-rank test. Univariable and multivariable Cox regression were performed to assess for impact of covariables on OS.

RESULTS

A total of 11 652 patients were included in the analysis. Median duration from surgery to radiation was 30 d. On multivariable regression, black race, larger tumor, gross-total resection, methyguanine-methyl transferase (MGMT+), and treatment at an academic facility were associated with a duration &gt;30 d. On multivariable analysis, there were no significant differences when comparing start within 24 d to 25 to 30 d (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.90-1.01, P = .13) or &gt; 37 d (HR 0.97, 95% CI 0.91-1.03, P = .26), although a small OS improvement was seen if initiated within 31 to 37 d (HR 0.93, 95% CI 0.88-0.99, P = .02).

CONCLUSION

There was no clear association between duration from surgery to initiation of chemoradiation on OS.

Bilateral diffuse grade 5 radiation pneumonitis after intensity modulated radiation therapy for localized lung cancer

We are reporting a case of fatal radiation pneumonitis that developed six months following chemoradiation for limited stage small cell lung cancer. The patient was a 67-year-old man with a past medical history of Hashimoto’s thyroiditis and remote suspicion for CREST, neither of which were active in the years leading up to treatment. He received 6600 cGy delivered in 200 cGy daily fractions via intensity modulated radiation therapy with concurrent cisplatin/etoposide followed by additional chemotherapy with dose-reduced cisplatin/etoposide and carboplatin/etoposide and then received prophylactic cranial irradiation. The subsequent months were notable for progressively worsening episodes of respiratory compromise despite administration of prolonged steroids and he ultimately expired. Imaging demonstrated bilateral interstitial and airspace opacities. Autopsy findings were consistent with pneumonitis secondary to chemoradiation as well as lymphangitic spread of small cell carcinoma. The process was diffuse bilaterally although his radiation was delivered focally to the right lung and mediastinum.

The Impact of Tobacco Use on Outcomes and Toxicity in a Predominantly Minority Population of Males with Prostate Cancer Receiving External Beam Radiation

INTRODUCTION

To investigate whether current or prior smoking history had any impact on prostate cancer outcomes and toxicity in our predominantly minority population of males receiving dose-escalated external beam radiation therapy (EBRT).

METHODS

Of the 500 patients treated with EBRT between 2003-2011, 444 had smoking histories recorded. Patients were classified as current smoker, former smoker, or never smoker. Biochemical failure-free survival (BFFS) and distant metastatic-free survival (DMFS) endpoints were analyzed. Multivariate Cox regression and multivariate logistic regression were used to assess whether smoking had an impact on outcomes and toxicity respectively.

RESULTS

There were 176 males (39.6%) classified as never smokers, 169 (38.1%) as prior smokers, and 99 (22.3%) as current smokers. The median follow-up was 76 months (range nine-146) and 61.9% of patients were African American. The eight-year BFFS for never smokers, prior smokers and current smokers was 73.6%, 80.2%, and 73.4% respectively, p=0.38. Similarly, the eight-year DMFS was 92.8%, 96.8%, and 95.3% respectively, p=0.54. On multivariate analysis, prior smoking (HR 0.72, p=0.19) and current smoking (HR 1.02, p=0.93) were not associated with increased biochemical failure. Similarly, smoking use was not associated with increased distant metastatic disease (hormone receptor (HR) 0.71, p=0.51 for prior smokers, HR 1.41, p=0.52 for current smokers). The presence of intermediate-risk disease (HR 2.87, p=0.002) was associated with an increased likelihood of biochemical failure. The high-risk disease was associated with both a higher risk of biochemical failure (HR 8.02, p <0.001) as well as distant metastatic disease (HR 17.61, p=0.01). On multivariate regression, prior or current smoking use was not associated with an increased likelihood of late grade two genitourinary or gastrointestinal toxicity.

CONCLUSION

Current or prior smoking use was not associated with inferior outcomes or increased toxicity in this study comprising a predominantly minority population undergoing dose escalated radiation therapy for prostate cancer.

Is There a Benefit to Prolonging the Interval Between Neoadjuvant Chemoradiation and Esophagectomy in Esophageal Cancer?

BACKGROUND

Evidence suggests that delaying surgical procedures may increase the rate of pathologic complete response (pCR) and that pCR is associated with improved overall survival (OS). In this study, the National Cancer Data Base (NCDB) was analyzed to evaluate this relationship in a large hospital-based registry.

METHODS

We identified patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma who received neoadjuvant chemoradiation (CRT) followed by esophagectomy from 2003 to 2012. Patients were stratified into quartiles based on the interval between the completion of CRT to operative treatment (≤40 days, 41-50 days, 51-63 days, and ≥64 days), and those with pT0N0M0 were classified as having pCR. Multivariate logistic regression was used to assess the impact of covariates on pCR, and multivariate Cox regression was used to assess their impact on OS.

RESULTS

The study population included 5,393 patients. Increasing the time interval to the surgical procedure was associated with an increased pCR rate (12.3% for ≤40 days to 18.3% for ≥64 days; p < 0.001). On multivariate analysis, a time interval greater than or equal to 51 days was associated with an increased likelihood of pCR (p = 0.009 for 51-63 days; p < 0.001 for ≥64 days), as was an increased radiation dose ≥50 Gy (p = 0.046 for 50-50.4 Gy; p = 0.02 for >50.4 Gy). Increasing the time interval was not associated with an improvement in OS for any quartile on multivariate analysis. In addition, OS was worse for those who underwent operation ≥64 days after completion of radiation therapy (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.01-1.33; p = 0.03).

CONCLUSIONS

Although increasing the time interval from CRT to surgical intervention was associated with a higher pCR rate, there was no improvement in survival.