Purpose: To validate whether prostate-specific antigen (PSA) level after neoadjuvant androgen suppression (neoAS) is associated with long-term outcome after neoAS and external beam radiation therapy (RT) with concurrent short-term androgen suppression (AS) in patients with prostate cancer. Methods and Materials: This study included 2404 patients. The patients were treated with neoAS before RT and concurrent AS (without post-RT AS) and were pooled from NRG Oncology/RTOG trials 9202, 9408, 9413, and 9910. Multivariable models were used to test associations between the prespecified dichotomized post-neoAS, pre-RT PSA level (<= 0.1 vs >0.1 ng/mL) groupings, and clinical outcomes. Results: The median follow-up for surviving patients was 9.4 years. The median post-neoAS, pre-RT PSA level was 0.3 ng/mL, with 32% of patients having levels <= 0.1 ng/mL. Race, Gleason score, tumor stage, node stage, pretreatment PSA level, and duration of neoAS were associated with the groups of patients with PSA levels <= 0.1 and >0.1 ng/mL. In univariate analyses, post- neoAS, pre-RT PSA level >0.1 ng/mL was associated with increased risks of biochemical failure (hazard ratio [HR], 2.04; P < .0001); local failure (HR, 2.51; P < .0001); distant metastases (HR, 1.73; P = .0006); cause-specific mortality (HR, 2.36; P < .0001); and all-cause mortality (HR, 1.24; P = .005). In multivariable models that also included baseline and treatment variables, post- neoAS, pre-RT PSA level >0.1 ng/mL was independently associated with increased risk of biochemical failure (HR, 2.00; P < .0001); local failure (HR, 2.33; P < .0001); and cause-specific mortality (HR, 1.75; P = .03). Conclusions: Patients with a PSA level >0.1 ng/mL after neoAS and before the start of RT had less favorable clinical outcomes than patients whose PSA level was <= 0.1 ng/mL. The role of post- neoAS, pre-RT PSA level relative to PSA levels obtained along the continuum of medical care is not presently defined but could be tested in future clinical trials. (C) 2019 Elsevier Inc. All rights reserved.

Salivary gland cancers are rare and represent approximately 5% of all head and neck cancers and only 0.3% of all malignancies. The majority (75%) of salivary gland tumors occur in the parotid gland, and while benign lesions are more common, mucoepidermoid carcinoma (MEC) makes up 40-50% of malignant parotid gland tumors. No randomized controlled trials exist regarding the role of adjuvant radiation for patients who undergo surgical resection of low-grade MECs. Herein, we report two cases of successful postoperative radiation therapy in low-grade, pT2N0 MEC of the parotid gland. The role of adjuvant radiation therapy for patients with MEC of the parotid gland is based on data from institution reviews and lacks data from randomized controlled trials. Per our review of the literature, the pathological findings of positive surgical margins and/or perineural invasion in two patients with low-grade MEC of the parotid gland warranted adjuvant radiation for improved local control after partial parotidectomy. Both patients tolerated postoperative radiation therapy with only mild side effects and, at last follow-up, five years after completion of therapy, had no clinical or radiographic evidence of either local recurrence or distant metastasis.

Primary lymphoma of the breast is a rare entity in the field of oncological medicine and represents <0.5% of all breast malignancies. A definitive diagnosis is obtained by excisional biopsy as the clinical and radiographical presentation is similar to the more common primary breast carcinoma. Unlike primary breast carcinoma, localized radiation therapy is the mainstay of treatment. We report on a case of primary follicular lymphoma of the breast in a 67-year-old Caucasian woman treated with localized radiation as well as coinciding literature review regarding outcomes of different treatment modalities.

BACKGROUND Very high levels of ionizing radiation exposure have been associated with the development of soft-tissue sarcoma. The effects of lower levels of ionizing radiation on sarcoma development are unknown. This study addressed the role of low to moderately high levels of ionizing radiation exposure in the development of soft-tissue sarcoma. METHODS Based on the Life Span Study cohort of Japanese atomic-bomb survivors, 80,180 individuals were prospectively assessed for the development of primary soft-tissue sarcoma. Colon dose in gray (Gy), the excess relative risk, and the excess absolute rate per Gy absorbed ionizing radiation dose were assessed. Subject demographic, age-specific, and survival parameters were evaluated. RESULTS One hundred and four soft-tissue sarcomas were identified (mean colon dose = 0.18 Gy), associated with a 39% five-year survival rate. Mean ages at the time of the bombings and sarcoma diagnosis were 26.8 and 63.6 years, respectively. A linear dose-response model with an excess relative risk of 1.01 per Gy (95% confidence interval [CI]: 0.13 to 2.46; p = 0.019) and an excess absolute risk per Gy of 4.3 per 100,000 persons per year (95% CI: 1.1 to 8.9; p = 0.001) were noted in the development of soft-tissue sarcoma. CONCLUSIONS This is one of the largest and longest studies (fifty-six years from the time of exposure to the time of follow-up) to assess ionizing radiation effects on the development of soft-tissue sarcoma. This is the first study to suggest that lower levels of ionizing radiation may be associated with the development of soft-tissue sarcoma, with exposure of 1 Gy doubling the risk of soft-tissue sarcoma development (linear dose-response). The five-year survival rate of patients with soft-tissue sarcoma in this population was much lower than that reported elsewhere.

The use of staging imaging modalities with increased sensitivity has led to an increase in the incidence of detection of simultaneous malignancies. These cases require careful evaluation and discussion in a multidisciplinary setting to establish a treatment plan that optimizes the outcome with respect to each malignancy, particularly when treatment modalities overlap. We report a case of a patient diagnosed with axillary nodal diffuse large B-cell lymphoma (DLBCL) in a community hospital where staging workup also revealed synchronous bilateral breast carcinomas. To our knowledge, this is only the second case report of a patient with three synchronous primary malignancies: bilateral breast carcinomas and axillary DLBCL. The only other similar case report had no role for radiation or chemotherapy in the management of the indolent follicular lymphoma.

To report on a suspected case of idiopathic radiation recall dermatitis in an individual nine months after radiation and chemotherapy treatment of squamous cell carcinoma of the right tonsil. Radiation recall dermatitis is the development of a reaction in a previously irradiated area of skin after the administration of an aggravating medication. A review of the literature revealed several cases of radiation recall dermatitis that occur following radiation therapy and the institution of chemotherapy. Other medications have also been implicated in radiation recall dermatitis; however, this patient has not started any new medications since completion of his combined therapy. The patient developed this skin reaction in a distribution pattern identical to the area that received the highest radiation dose suggesting a possible link between radiation recall dermatitis and radiation dose. Radiation recall dermatitis is a reaction that is typically seen shortly after the reinstitution of chemotherapy during radiation therapy. This case illustrates that other medical etiologies are possible and suggests a relationship between radiation recall dermatitis and the total radiation dose an area receives.

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm microscopically similar to undifferentiated nasopharyngeal carcinoma. It is typically nonaggressive and is treated with wide local excision. However, we present a case of a patient with a regional recurrence and more aggressive LELCS with perineural invasion and positive margins for which he was treated with wide local excision followed by chemoradiation. We discuss the use of chemoradiation for this patient and review the literature, specifically pertaining to treatment of more aggressive cases of LELCS.

The evaluation and treatment of the internal mammary nodes (IMNs) in patients with axillary node positive breast cancer undergoing breast conservation therapy is somewhat controversial. A recently reported randomized trial of radiation therapy to the local regional nodes (including the IMNs) in patients undergoing breast conservation therapy demonstrated an improvement in disease free survival and overall survival with this additional nodal irradiation. For patients with tumors in the medial quadrants of the breast, consideration of peritumoral sentinel lymph node procedures with or without periareolar injections should be considered as demonstrated lymphatic drainage to the IMNs may indicate a greater need to consider their inclusion in adjuvant radiation therapy fields, regardless of clinical or radiographic involvement. These nodes may be treated either with a separate IMN field or partially-wide tangents. The benefits of this inclusion must be weighed against the risks of side effects of increased radiation exposure of lung, heart and contralateral breast tissue. Additional long-term data from randomized trials currently underway and maturing may help to define the risks versus the benefits of IMN elective nodal irradiation

Small cell lung cancer (SCLC) constitutes approximately 16% of all primary lung cancers, with more than 35,000 new cases per year. Two-thirds of patients present with extensive stage disease (ES-SCLC) due to a tendency to metastasize early. Outcomes remain poor, with a median survival of approximately 10 months and a two-year overall survival of <10%. Current recommendations call for combination chemotherapy alone in patients without localized symptoms. Thoracic radiation therapy following a good clinical response is controversial. We report on a patient with ES-SCLC that had an excellent response to chemotherapy and underwent whole brain radiotherapy for a known brain metastasis and consolidative radiotherapy to the thorax. His latest follow-up demonstrates only a stable residual pulmonary nodule and no evidence of active metastatic disease. ES-SCLC is a relatively common presentation with a variable burden of metastatic disease. In the absence of randomized trials demonstrating the efficacy of thoracic radiation therapy, the community radiation oncologist is placed in a difficult position when addressing these patients, particularly those with otherwise good performance status and a good response to initial systemic chemotherapy. More research in this area is sorely needed to help guide treatment recommendations.

Hemangiopericytoma is a rare vascular malignancy, comprising approximately 1% of all vascular neoplasms, and arises from the pericytes of Zimmerman. 1 Borg M.F. Benjamin C.S. A 20-year review of haemangiopericytoma in Auckland, New Zealand. Clin Oncol (R Coll Radiol). 1994; 6: 371-376 Abstract Full Text PDF PubMed Scopus (13) Google Scholar It was first described by Stout in 1949. 2 Stout A.P. Hemangiopericytoma: a study of 25 cases. Cancer. 1949; 2: 1027-1054 Crossref PubMed Scopus (204) Google Scholar The most common sites of presentation are the lower extremity, axilla, pelvis, retroperitoneum, and head and neck. 3 Enzinger F.M. Smith B.H. Hemangiopericytoma. An analysis of 106 cases. Hum Pathol. 1976; 7: 61-82 Abstract Full Text PDF PubMed Scopus (728) Google Scholar , 4 Espat N.J. Lewis J.J. Leung D. et al. Conventional hemangiopericytoma: modern analysis of outcome. Cancer. 2002; 95: 1746-1751 Crossref PubMed Scopus (151) Google Scholar Most patients present with a mass or localized pain. The lesions are histologically similar to solitary fibrous tumors, and because of this similarity, previous work on the identification and appropriate therapy for this rare malignancy is complicated by the likely inclusion of perhaps a more aggressive sarcoma in retrospective reviews. 5 Koch M. Nielsen G.P. Yoon S.S. Malignant tumors of blood vessels: angiosarcomas, hemangioendotheliomas, and hemangioperictyomas. J Surg Oncol. 2008; 97: 321-329 Crossref PubMed Scopus (75) Google Scholar

Anal canal cancer is rare, accounting for only 1.3% of all gastrointestinal tract malignancies. Prostate cancer incidence is much higher and accounts for 27.6% of all malignancies in men. Treatment guidelines for anal cancer involve radiotherapy to the primary site and draining lymphatics while treatment for prostate cancer can also include pelvic radiotherapy. The literature is silent on the optimum course of action when these two malignancies are found synchronously or metachronously. Herein, we report a case of a patient diagnosed with intermediate risk prostate cancer who, prior to definitive therapy for this first malignancy, was also diagnosed with anal canal cancer. We conclude that a simultaneous approach with radiation therapy and chemotherapy with subsequent boost to the prostate is recommended. Screening for synchronous prostate cancer in male anal canal cancer patients is probably indicated and may preclude suboptimal treatment for a second occult primary.

The aim of this paper is to report on the challenges associated with identifying disease recurrence following combined modality therapy (CMT) for primary lymphoma of the tibia in which an intramedullary nail has been placed. A patient with primary bone lymphoma (PBL) was treated with CMT (chemotherapy and radiation therapy). After a complete response, he has been followed for eighteen months by physical exam and radiographic imaging. Despite persistent increased tracer accumulation at the original site, he has no proven recurrence. Literature review showed a small number of retrospective, single institution reviews detailing clinical experience and expected outcome in patients treated with PBL limited to one bony site of disease. PBL presents a treatment challenge, particularly when a weight-bearing long bone is diffusely involved and followup is complicated after placement of stabilizing hardware. Close coordination of the oncology team and diagnostic radiology is required to ensure optimal outcome.

Background: Radiation-induced bone sarcoma has been associated with high doses of ionizing radiation from therapeutic or occupation-related exposures. However, the development of bone sarcoma following exposure to lower doses of ionizing radiation remains speculative. Methods: A cohort analysis based on the Life Span Study (n = 120,321) was performed to assess the development of bone sarcoma in atomic-bomb survivors of Hiroshima and Nagasaki followed from 1958 to 2001. The excess relative risk per gray of ionizing radiation absorbed by the bone marrow was estimated. Additional subject demographic, survival, and clinical factors were evaluated. Results: Nineteen cases of bone sarcoma (in eleven males and eight females) were identified among the 80,181 subjects who met the inclusion criteria, corresponding to an incidence of 0.9 per 100,000 person-years. The mean ages at the time of the bombing and at diagnosis were 32.4 and 61.6 years, respectively. The mean bone marrow dose was 0.43 Gy. Osteosarcoma was the most commonly identified bone sarcoma. The most common bone sarcoma site was the pelvis. The overall unadjusted five-year survival rate was 25%. A dose threshold was found at 0.85 Gy (95% confidence interval, 0.12 to 1.85 Gy), with a linear dose-response association above this threshold. The linear slope equaled an excess relative risk of 7.5 per Gy (95% confidence interval, 1.34 to 23.14 per Gy) in excess of 0.85 Gy. Conclusions: On the basis of what we believe is one of the longest and largest prospective studies assessing the development of bone sarcoma in individuals exposed to ionizing radiation, it appears that the development of radiation-induced bone sarcoma may be associated with exposure to much lower doses of ionizing radiation than have previously been reported. Such new insights may potentially improve bone sarcoma prevention measures and broaden our understanding of the role of ionizing radiation from various sources on the development of malignant tumors. This study stresses the need to become increasingly aware of the various health risks that may be attributable to even low levels of ionizing radiation exposure. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

PURPOSE: To report on the safe and effective use of a prostate brachytherapy implant for clinically low-risk prostate cancer in a patient with previous ileal pouch anal anastomosis.METHODS AND MATERIALS: A patient with a previous history of total proctocolectomy with ileal pouch anal anastomosis was diagnosed with low-risk prostate cancer. He underwent prostate brachytherapy implant and his urinary, bowel, and sexual function were monitored preoperatively and regularly after his implant.RESULTS: Approximately 1-year postimplant, the patient's serum prostate-specific antigen continued to decrease and urinary obstructive symptoms measured via a standardized patient-reported instrument increased transiently but returned to baseline. His sexual function remains slightly diminished. His self-reported bowel function has been essentially unchanged, and he specifically denies increased stool frequency, urgency, incontinence, tenesmus, or hematochezia.CONCLUSIONS: Prostate brachytherapy appears to be both safe and effective for treating low-risk prostate cancer in patients with a pre-existing deal pouch-anal anastomosis. Although there is a potential for significant late injury to the neorectum, a previous small series indicated that this had not been seen. Models currently used to predict normal tissue complication probabilities do not seem well applied to this case. The developments of algorithms that more correctly model this condition are encouraged. Published by Elsevier Inc. All rights reserved.

Background and purpose Chest wall recurrences of breast cancer are a therapeutic challenge and durable local control is difficult to achieve. Our objective was to determine the local progression free survival (LPFS) and toxicity of thermochemoradiotherapy (ThChRT) for chest wall recurrence. Methods Twenty-seven patients received ThChRT for chest wall failure from 2/1995 to 6/2007 and make up this retrospective series. All received concurrent superficial hyperthermia twice weekly (median 8 sessions), chemotherapy (capecitabine in 21, vinorelbine in 2, and paclitaxel in 4), and radiation (median 45 Gy). Patients were followed up every 1.5–3 months and responses were graded with RECIST criteria and toxicities with the NCI CTC v4.0. Results Twenty-three (85%) patients were previously irradiated (median 60.4 Gy) and 22 (81%) patients received prior chemotherapy. Median follow-up was 11 months. Complete response (CR) was achieved in 16/20 (80%) of patients with follow-up data, and 1 year LPFS was 76%. Overall survival was 23 months for patients with CR, and 5.4 months in patients achieving a partial response (PR) (p = 0.01). Twenty-two patients experienced acute grade 1/2 treatment related toxicities, primarily moist desquamation. Two patients experienced 3rd degree burns; all resolved with conservative measures. Conclusions ThChRT offers durable palliation and prolonged LPFS with tolerable acute toxicity, especially if CR is achieved.

Purpose: To assess the impact of increasing experience with intensity-modulated radiation therapy (IMRT) after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM). 3Methods and Materials: The records of all patients who received IMRT following EPP at Duke University Medical Center between 2005 and 2010 were reviewed. Target volumes included the preoperative extent of the pleural space, chest wall incisions, involved nodal stations, and a boost to close/positive surgical margins if applicable. Patients were typically treated with 9-11 beams with gantry angles, collimator rotations, and beam apertures manually fixed to avoid the contalateral lung and to optimize target coverage. Toxicity was graded retrospectively using National Cancer Institute common toxicity criteria version 4.0. Target coverage and contralateral lung irradiation were evaluated over time by using linear regression. Local control, disease-free survival, and overall survival rates were estimated using the Kaplan-Meier method.Results: Thirty patients received IMRT following EPP; 21 patients also received systemic chemotherapy. Median follow-up was 15 months. The median dose prescribed to the entire ipsilateral hemithorax was 45 Gy (range, 40-50.4 Gy) with a boost of 8-25 Gy in 9 patients. Median survival was 23.2 months. Two-year local control, disease-free survival, and overall survival rates were 47%, 34%, and 50%, respectively. Increasing experience planning MPM cases was associated with improved coverage of planning target volumes (P=.04). Similarly, mean lung dose (P<.01) and lung V5 (volume receiving 5 Gy or more; P<.01) values decreased with increasing experience. Lung toxicity developed after IMRT in 4 (13%) patients at a median of 2.2 months after RT (three grade 3-4 and one grade 5). Lung toxicity developed in 4 of the initial 15 patients vs none of the last 15 patients treated.Conclusions: With increasing experience, target volume coverage improved and dose to the contralateral lung decreased. Rates of pulmonary toxicity were relatively low. However, both local and distant control rates remained suboptimal. (C) 2012 Elsevier Inc.

Purpose. There is evidence in the literature of increased maternal radiosensitivity during pregnancy. Materials and Methods. We tested this hypothesis using information from the atomic-bomb survivor cohort, that is, the Adult Health Study database at the Radiation Effects Research Foundation, which contains data from a cohort of women who were pregnant at the time of the bombings of Hiroshima and Nagasaki. Previous evaluation has demonstrated long-term radiation dose-response effects. Results/Conclusions. Data on approximately 250 women were available to assess dose-response rates for serum cholesterol, white blood cell count, erythrocyte sedimentation rate, and serum hemoglobin, and on approximately 85 women for stable chromosome aberrations, glycophorin A locus mutations, and naïve CD4 T-cell counts. Although there is no statistically significant evidence of increased radiosensitivity in pregnant women, the increased slope of the linear trend line in the third trimester with respect to stable chromosome aberrations is suggestive of an increased radiosensitivity.