Outcomes of patients with stage I-II Hodgkin lymphoma who had uniform

PurposeHistorically, the standard of care for total skin electron beam therapy (TSEBT) delivered 30 to 36 Gy over 5 to 10 weeks. Given the high risk of relapse, a majority of patients require additional treatments. Therefore, attempts to use a shortened course of TSEBT have been investigated.Methods and MaterialsWe conducted a single-institution retrospective review to evaluate disease response, control, and toxicity using a low-dose, hypofractionated course of TSEBT (HTSEBT) in patients with mycosis fungoides.ResultsForty patients received 57 courses of HTSEBT. Median dose (Gy)/fractionation was 12/3, spanning a median time of 2.4 weeks. Overall response rate of patients assessed (n = 54) was 100%. Thirty-one courses (57.4%) resulted in a complete response and 23 courses (42.6%) resulted in a partial response. Cumulative incidence of progressive skin disease at 3 months was 37.2%, at 6 months, 56.9%, and at 1 year, 81.5%. Of the 40 patients treated with a first course of HTSEBT, 31 received subsequent courses of radiotherapy. Cumulative incidence of subsequent treatment was 28.0% at 3 months, 46.8% at 6 months, and 70.0% at 1 year. Patients who underwent repeat courses of HTSEBT continued to have similar treatment responses to repeat courses without increased toxicities. Toxicities from all courses were acceptable with the exception of 1 patient, who experienced grade 4 skin toxicity (moist desquamation requiring hospitalization).ConclusionsLow-dose HTSEBT provides good palliation in patients with cutaneous T-cell lymphoma with a satisfactory response and toxicity profile. HTSEBT allows therapy to be completed in far fewer treatments. Low-dose HTSEBT is an appropriate treatment option for patients unable to come for daily treatment. HTSEBT provides a way to decrease exposure to other patients and staff during public health emergencies such as the coronavirus disease 2019 (COVID-19) pandemic.

Purpose: Electrocardiogram-gated computed tomography with coronary angiography can be used for cardiac substructure sparing (CSS) optimization, which identifies and improves avoidance of cardiac substructures when treating with intensity modulated radiotherapy (IMRT). We investigated whether intensity modulated proton therapy (IMPT) would further reduce dose to cardiac substructures for patients with mediastinal lymphoma. Patients and Methods: Twenty-one patients with mediastinal lymphoma were enrolled and underwent electrocardiogram-gated computed tomography angiography during or shortly after simulation for radiotherapy planning. Thirteen patients with delineated cardiac substructures underwent comparative planning with both IMPT and IMRT. Plans were normalized for equivalent (95%) target volume coverage for treatment comparison. Results: Thirteen patients met criteria for this study. The median size of the mediastinal lymphadenopathy was 7.9 cm at the greatest diameter. Compared with IMRT-CSS, IMPT-CSS significantly reduced mean dose to all cardiac substructures, including 3 coronary arteries and 4 cardiac valves. Use of IMPT significantly reduced average whole-heart dose from 9.6 to 4.9 Gy (P<.0001), and average mean lung dose was 9.7 vs 5.8 Gy (P<.0001). Prospectively defined clinically meaningful improvement was observed in at least 1 coronary artery in 9 patients (69%), at least 1 cardiac valve in 10 patients (77%), and whole heart in all 13 patients. Conclusions: For patients with mediastinal lymphoma, IMPT-CSS treatment planning significantly reduced radiation dose to cardiac substructures. The significant improvements outlined in this study for proton therapy suggest possible clinical improvement in alignment with previous analyses of CSS optimization.

To compare, in a large multi-institutional study, the adverse events (AEs) and oncologic efficacy associated with curative-intent intensity modulated photon radiotherapy (IMRT) and pencil beam scanning intensity modulated proton therapy (IMPT) in the management of patients with squamous cell carcinoma of the anal canal. This was a retrospective cohort study of patients with squamous cell carcinoma of the anal canal treated with curative-intent radiotherapy between 2013 and 2018 at three tertiary care centers and multiple affiliated network sites. Clinical target volumes were delineated similarly to RTOG consensus guidelines. IMRT was most commonly delivered with rotational arc therapy. IMPT was delivered with posterior oblique fields with or without anterior inguinal fields. Primary endpoints were acute grade 3 or higher AEs as assessed per Common Terminology Criteria for AEs v4. Secondary endpoints included late AEs, overall survival (OS), colostomy-free survival (CFS), progression-free survival (PFS), colostomy failure (CF), and locoregional failure (LRF) reported as Kaplan-Meier or cumulative incidence estimates. A total of 208 patients were included and received either IMRT (n=150) or IMPT (n=58). Median age was 62 years (range 23-88), 73% were women, and 12% were HIV-positive. Clinical stage was I (13%), II (36%), IIIA (12%), IIIB (38%), or IV (1%). Lymph node positive disease was more common in the IMRT cohort (57% vs. 31%, p=0.001). Median RT dose was 54 Gy (interquartile range [IQR] 51.25-54) in 30 (IQR 28-30) fractions, and was comparable between cohorts. Concurrent chemotherapy was given to 99% of patients, and included 5-fluorouracil + mitomycin C (87%), capecitabine + mitomycin C (8%), 5-fluorouracil + cisplatin (3%), or capecitabine alone (1%). Median follow-up was 30 months. Acute and late AEs and oncologic outcomes are detailed in the Table. All endpoints were similar between treatment cohorts. Hospitalization occurred in 32% of patients receiving IMRT and 40% of patients receiving IMPT (p=0.33). IMPT was associated with AEs and short term efficacy (2 years) comparable with IMRT. Additional follow up of this cohort will determine if important differences arise in late toxicities and if further prospective evaluation is warranted.Abstract 1086; Table 1Summary of treatment-related AEs and oncologic outcomes.EndpointIMRT (%)IMPT (%)P-valueAcute Grade 3+ AEsGastrointestinal (GI)20220.71Genitourinary (GU)120.48GI/GU21240.58Dermatologic23210.85Hematologic47540.43Pain13121.0Overall66661.0Late Grade 3+ AEsαGI200.68GU020.73GI/GU220.49Oncologic OutcomesOverall survivalβ91960.39Colostomy-free survivalβ85900.30Progression-free survivalβ84910.32Colostomy Failureα860.46Locoregional Failureα780.97Reported as 2-year cumulative incidence estimateα or Kaplan-Meier estimateβ Open table in a new tab

Purpose: (1) Demonstrate feasibility of electrocardiogram-gated computed tomography with coronary angiography (E-CTA) in treatment planning for mediastinal lymphoma and (2) assess whether inclusion of cardiac substructures in the radiation plan optimization (CSS optimization) results in increased cardiac substructure sparing. Methods and Materials: Patients with mediastinal lymphomas requiring radiation therapy were prospectively enrolled in an observational study. Patients completed a treatment planning computed tomography scan and E-CTA in the deep inspiration breath hold position. Avoidance structures (eg, coronary arteries and cardiac valves) were created in systole and diastole and then merged into a single planning organ-at-risk volume based on a cardiac substructure contouring atlas. In the photon cohort, 2 volumetric modulated arc therapy plans were created per patient with and without CSS optimization. Dosimetric endpoints were compared. Results: In the photon cohort, 7 patients were enrolled. For all 7 patients, the treating physician elected to use the CSS optimization plan. At the individual level, 2 patients had reductions of 10.8% and 16.2% of the right coronary artery receiving at least 15 Gy, and 1 had a reduction of 9.6% of the left anterior descending artery receiving 30 Gy. No other differences for coronary arteries were detected between 15 and 30 Gy. Conversely, 5 of 7 patients had >10% reductions in dose between 15 to 30 Gy to at least 1 cardiac valve. The greatest reduction was 22.8% of the aortic valve receiving at least 30 Gy for 1 patient. At the cohort level, the maximum, mean, and 5-Gy increment analyses were nominally similar between planning techniques for all cardiac substructures and the lungs. Conclusions: Cardiac substructure delineation using E-CTA was feasible, and inclusion in optimization led to modest improvements in sparing of radiosensitive cardiac substructures for some patients. (C) 2019 Published by Elsevier Inc. on behalf of American Society for Radiation Oncology.

The dose, volume, and treatment field of radiation therapy can generally be used to predict the risks of immediate and late adverse events. However, radiation recall reactions can unexpectedly affect patients who receive systemic therapy after a course of radiation therapy. Radiation recall dermatitis is the most common recall reaction. Herein, we describe a case of radiation recall mucosal toxicity of the upper aerodigestive tract in a patient who received multiple chemotherapy regimens.

Background: Focal or total skin radiation therapy can be used to treat mild to refractory cutaneous T-cell lymphoma. Objective: To report the broad therapeutic benefit of radiation therapy for cutaneous T-cell lymphoma. Methods: Retrospective, single-institution review of outcomes for skin-directed radiation therapy. Results: Skin-directed radiation therapy showed a 99% response rate and 80% complete response rate after treatment regardless of involvement, severity, histopathologic subtype, dose, or fractionation. The overall in-field recurrence rate was 15%, and median time to recurrence was 296 days (range, 1-1884 days). Focal and hypofractionated regimens were similarly associated with disease response and rare toxicity. Shortterm rates of secondary skin cancer after treatment were comparable to expected incidence in a patient population without radiation. Limitations: Large total number of treatments courses compared with overall number of patients. Heterogenous mix of treatment regimens (no standardization of dose or fraction number). Conclusions: Radiation therapy is a well-tolerated treatment option for properly selected patients with cutaneous T-cell lymphoma.

Palmoplantar pustulosis (PPP) is an often refractory and symptomatic dermatosis. Despite the often proportionally smaller involved percentage of body surface area, the disease can have a disproportionately negative impact on quality of life.1Pettey A.A. Balkrishnan R. Rapp S.R. Fleischer A.B. Feldman S.R. Patients with palmoplantar psoriasis have more physical disability and discomfort than patients with other forms of psoriasis: implications for clinical practice.J Am Acad Dermatol. 2003; 49: 271-275Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar We recently used skin-directed radiation therapy (RT) for treatment of severe, refractory PPP. Clinicians often use ultraviolet radiation therapy as first-line treatment of PPP. Although ionizing radiation (particularly Grenz ray irradiation) was extensively used for focal inflammatory dermatoses, recently its use has been largely abandoned. New techniques such as megavoltage beams (when appropriate) have provided an opportunity to use RT in patients with more extensive disease. RT as treatment of PPP is rarely described and with varying efficacy.2Timerman D. Devlin P.M. Nambudiri V.E. et al.Novel application of high-dose rate brachytherapy for severe, recalcitrant palmoplantar pustulosis.Clin Exp Dermatol. 2016; 41: 498-501Crossref PubMed Scopus (6) Google Scholar A published report from our department, describing extensive, refractory dermatitis responding to RT, was the impetus to treat the patients described here.3Sio T. Pittelkow M.R. Nagle M.A. Martenson J.A. External beam radiation therapy for recalcitrant dermatitis.Acta Derm Venereol. 2014; 94: 717-719Crossref PubMed Scopus (2) Google Scholar We describe 2 cases of refractory, symptomatically debilitating PPP with dramatic short-term response to RT. A 44-year-old woman suffered from severe, refractory PPP with debilitating 10/10 pain limiting her ability to walk. Over 2 years, she had little relief from topical steroids, topical calcineurin inhibitors, calcipotriene, and systemic medications including apremilast, prednisone, methotrexate, cyclosporine, acitretin, and ustekinumab. She underwent RT to the hands and feet (18 Gy in 6 fractions, 3 Gy once weekly). She noted dramatic improvement after the first 2 treatments and was pain free after the fourth treatment. At 1-month follow-up, she reported no pain or difficulty walking (Fig 1). At 13-month follow-up, she reported complete clearance lasting 5 months after RT, followed by recurrence at the prior level of severity. The patient declined subsequent treatments because of inability to travel. A 49-year-old woman presented with severe PPP for 10 years that limited her ability to ambulate. She was refractory to topical corticosteroids, salicylic acid, ultraviolet light therapy, and systemic medications (prednisone, methotrexate, infliximab, adalimumab, etanercept, ustekinumab, acitretin, apremilast, and ixekizumab). She underwent RT to the hands and feet (18 Gy in 6 fractions, 3 Gy once weekly) and experienced dramatic improvement within 3 treatments. Her ability to freely ambulate returned. Follow-up at 1 month showed continued improvement with decreased pain (1/10 compared to 10/10 before RT) (Fig 2). At 16-month follow-up, she reported sustained improvement with mild once-monthly flares controlled topically. All treatments were well tolerated and all reported side effects were mild (fatigue, dry skin). Megavoltage beams were required in both cases to cover the entire extent of disease with adequate dose. Phase 3 clinical trials found that superficial RT is well tolerated and is effective in the treatment of focal eczema.4Cartwright P.H. Rowell N.R. Comparison of Grenz rays versus placebo in the treatment of chronic hand eczema.Br J Dermatol. 1987; 117: 73-76Crossref PubMed Scopus (26) Google Scholar, 5Fairris G.M. Jones D.H. Mack D.P. Rowell N.R. Conventional superficial X-ray versus Grenz ray therapy in the treatment of constitutional eczema of the hands.Br J Dermatol. 1985; 112: 339-341Crossref PubMed Scopus (36) Google Scholar, 6King C.M. Chalmers R.J. A double-blind study of superficial radiotherapy in chronic palmar eczema.Br J Dermatol. 1984; 111: 451-454Crossref PubMed Scopus (29) Google Scholar, 7Lindelof B. Wrangsjo K. Liden S. A double-blind study of Grenz rady therapy in chronic eczema of the hands.Br J Dermatol. 1987; 117: 77-80Crossref PubMed Scopus (52) Google Scholar, 8Fairris G.M. Mack D.P. Rowell N.R. Superficial X-ray therapy in the treatment of constitutional eczema of the hands.Br J Dermatol. 1984; 111: 445-449Crossref PubMed Scopus (36) Google Scholar In one study, superficial x-rays were found to be more effective than x-rays.4Cartwright P.H. Rowell N.R. Comparison of Grenz rays versus placebo in the treatment of chronic hand eczema.Br J Dermatol. 1987; 117: 73-76Crossref PubMed Scopus (26) Google Scholar Technical advances, including the use of megavoltage9Duff M. Cruchfield C.E. Moore J. Farniook K. Potish R.A. Gallego H. Radiation therapy for chronic vesicular hand dermatitis.Dermatitis. 2006; 17: 128-132Crossref PubMed Scopus (6) Google Scholar and intensity-modulated RT3Sio T. Pittelkow M.R. Nagle M.A. Martenson J.A. External beam radiation therapy for recalcitrant dermatitis.Acta Derm Venereol. 2014; 94: 717-719Crossref PubMed Scopus (2) Google Scholar have made it possible to use RT for treatment in patients with more extensive disease. In our previous report we described the successful use of intensity-modulated RT in a patient with extensive dermatitis.3Sio T. Pittelkow M.R. Nagle M.A. Martenson J.A. External beam radiation therapy for recalcitrant dermatitis.Acta Derm Venereol. 2014; 94: 717-719Crossref PubMed Scopus (2) Google Scholar Use of ionizing radiation for inflammatory conditions of the skin has been mostly abandoned in recent decades. Our experience shows that RT is a treatment option for severe, refractory PPP and some other inflammatory dermatoses, including extensive multi-focal disease. The use of ionizing radiation therapy should be considered along with other forms of photon therapy, including ultraviolet A1 phototherapy and ultraviolet B phototherapy10Su L.N. Ren J. Cheng S.M. Ding Y.F. Zhu N.W. UVA1 vs. narrowband UVB phototherapy in the treatment of palmoplantar pustulosis: a pilot randomized controlled study.Lasers Med Sci. 2017; 32: 1819-1823Crossref PubMed Scopus (15) Google Scholar in the treatment of PPP. Radiation oncologists should consider this treatment to be within the scope of their practice and it should be considered within the standard of care for third-party coverage. Because of the risk of radiation-induced skin cancer, use should be reserved for patients with severe, symptomatic disease refractory to other treatments.

Objective: To determine whether N-acetylcysteine rinse was safe and could improve thickened secretions and dry mouth during and after radiotherapy. Patients and Methods: We designed a prospective pilot double-blind, placebo-controlled randomized clinical trial (Alliance MCI 3C2). Adult patients (age >= 18 years) were enrolled if they underwent chemoradiotherapy (>= 60 Gy). Patients initiated testing rinse within 3 days of starting radiotherapy. With swish-and-spit, they received 10% N-acetylcysteine (2500 mg daily) or placebo rinse solution 5 times daily during radiotherapy and 2 weeks postradiotherapy. The primary aim was to evaluate N-acetylcysteine in improvement of saliva viscosity with the Groningen Radiotherapy-Induced Xerostomia questionnaire. Secondary aims included evaluating xerostomia improvement by the same questionnaire and with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck-35 Questions survey and adverse-event profiles. The type I error rate was 20%. Results: Thirty-two patients undergoing chemoradiotherapy were enrolled. Baseline characteristics were balanced for placebo (n=17) and N-acetylcysteine (n=15). N-acetylcysteine was better for improving sticky saliva (area under curve, P=.12). Scores of multiple secondary end points favored N-acetylcysteine, including sticky saliva daytime (P=.04), daytime and total xerostomia (both P=.02), pain (P=.18), and trouble with social eating (P=.15). Repeated measures models confirmed the findings. Taste was a major dissatisifer for N-acetylcysteine rinse; however, both testing rinses were safe and well tolerated overall. Conclusion: Our pilot data showed that N-acetylcysteine rinse was safe and provided strong evidence of potential efficacy for improving thickened saliva and xerostomia by patient-reported outcome. A confirmatory phase 3 trial is required. (C) 2019 Mayo Foundation for Medical Education and Research

Importance Oral mucositis causes substantial morbidity during head and neck radiotherapy. In a randomized study, doxepin mouthwash was shown to reduce oral mucositis–related pain. A common mouthwash comprising diphenhydramine-lidocaine-antacid is also widely used. Objective To evaluate the effect of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash for the treatment of oral mucositis–related pain. Design, Setting, and Participants A phase 3 randomized trial was conducted from November 1, 2014, to May 16, 2016, at 30 US institutions and included 275 patients who underwent definitive head and neck radiotherapy, had an oral mucositis pain score of 4 points or greater (scale, 0-10), and were followed up for a maximum of 28 days. Interventions Ninety-two patients were randomized to doxepin mouthwash (25 mg/5 mL water); 91 patients to diphenhydramine-lidocaine-antacid; and 92 patients to placebo. Main Outcome and Measures The primary end point was total oral mucositis pain reduction (defined by the area under the curve and adjusted for baseline pain score) during the 4 hours after a single dose of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash compared with a single dose of placebo. The minimal clinically important difference was a 3.5-point change. The secondary end points included drowsiness, unpleasant taste, and stinging or burning. All scales ranged from 0 (best) to 10 (worst). Results Among the 275 patients randomized (median age, 61 years; 58 [21%] women), 227 (83%) completed treatment per protocol. Mucositis pain during the first 4 hours decreased by 11.6 points in the doxepin mouthwash group, by 11.7 points in the diphenhydramine-lidocaine-antacid mouthwash group, and by 8.7 points in the placebo group. The between-group difference was 2.9 points (95% CI, 0.2-6.0; P = .02) for doxepin mouthwash vs placebo and 3.0 points (95% CI, 0.1-5.9; P = .004) for diphenhydramine-lidocaine-antacid mouthwash vs placebo. More drowsiness was reported with doxepin mouthwash vs placebo (by 1.5 points [95% CI, 0-4.0]; P = .03), unpleasant taste (by 1.5 points [95% CI, 0-3.0]; P = .002), and stinging or burning (by 4.0 points [95% CI, 2.5-5.0]; P < .001). Maximum grade 3 adverse events for the doxepin mouthwash occurred in 3 patients (4%); diphenhydramine-lidocaine-antacid mouthwash, 3 (4%); and placebo, 2 (2%). Fatigue was reported by 5 patients (6%) in the doxepin mouthwash group and no patients in the diphenhydramine-lidocaine-antacid mouthwash group. Conclusions and Relevance Among patients undergoing head and neck radiotherapy, the use of doxepin mouthwash or diphenhydramine-lidocaine-antacid mouthwash vs placebo significantly reduced oral mucositis pain during the first 4 hours after administration; however, the effect size was less than the minimal clinically important difference. Further research is needed to assess longer-term efficacy and safety for both mouthwashes. Trial Registration ClinicalTrials.gov Identifier: NCT02229539

Purpose: Grade 4 lymphopenia (G4L) during radiation therapy (RT) is associated with higher rates of distant metastasis and decreased overall survival in a number of malignancies, including esophageal cancer (EC). Through a reduction in integral radiation dose, proton RT (PRT) may reduce G4L relative to photon RT (XRT). The purpose of this study was to compare G4L in patients with EC undergoing PRT versus XRT. Methods and materials: Patients receiving curative-intent RT and concurrent chemotherapy for EC were identified. Lymphocyte nadir was defined as the lowest lymphocyte count during RT. G4L was defined as absolute lymphocyte count <200/mm(3). Univariate and multivariable logistic regression analyses (MVA) were performed to assess patient and treatment factors associated with lymphopenia. A propensity-matched (PM) cohort was created using logistic regression, including baseline covariates. Results: A total of 144 patients met the inclusion criteria. The median age was 66 years (range, 32-85 years). Of these patients, 79 received XRT (27% 3-dimensional chemo-RT and 73% intensity modulated RT) and 65 received PRT (100% pencil-beam scanning). Chemotherapy consisted of weekly carboplatin and paclitaxel (99%). There were no significant differences in baseline characteristics between the groups, except for age (median 4 years older in the PRT cohort). G4L was significantly higher in patients who received XRT versus those who received PRT (56% vs 22%; P < .01). On MVA, XRT (odds ratio [OR]: 5.13; 95% confidence interval [CI], 2.35-11.18; P < .001) and stage III/IV (OR: 4.54; 95% CI, 1.87-11.00; P < .001) were associated with G4L. PM resulted in 50 PRT and 50 XRT patients. In the PM cohort, G4L occurred in 60% of patients who received XRT versus 24% of patients who received PRT. On MVA, XRT (OR: 5.28; 95% CI, 2.14-12.99; P < .001) and stage III/IV (OR: 3.77; 95% CI, 1.26-11.30; P = .02) were associated with G4L. Conclusions: XRT was associated with a significantly higher risk of G4L in comparison with PRT. Further work is needed to evaluate a potential association between RT modality and antitumor immunity as well as long-term outcomes. (C) 2018 The Authors. Published by Elsevier Inc. on behalf of American Society for Radiation Oncology.

To report our institutional experience utilizing stereotactic body radiation therapy (SBRT) for patients with oligometastatic or oligoprogressive colorectal cancer (CRC). Following institutional review board approval, a retrospective chart review was performed to identify patients with oligometastatic or oligoprogressive CRC who received metastasis-directed SBRT. Patient characteristics, treatment characteristics, and oncologic outcomes were collected. Overall survival (OS) from end of first SBRT and local control (LC) were estimated using Kaplan-Meier methods and cumulative incidences, respectively. A total of 85 patients (31 male, 54 female) and 107 lesions were treated between 2008 and 2017. Median follow-up was 20 months (interquartile range [IQR] 10, 41). Median age was 62 (IQR 53, 70). The primary tumor site was colon (63%) or rectum (37%). Forty-one (48%) patients were diagnosed with metastatic disease at initial disease diagnosis. At metastatic diagnosis, most patients were found to have ≤5 metastatic lesions (93%), with most having involvement of 1 (83%) or 2 (14%) organs. Median time from development of metastasis to SBRT was 30 months (IQR 15, 52). All patients received chemotherapy prior to first SBRT. The majority (84%) of patients received other modalities of metastasis-directed local therapy prior to SBRT, including surgery (66%), ablative procedure (34%), conventional palliative dose radiotherapy (RT) (21%), or embolization (2%). Median lesion size treated with SBRT was 2.2 cm (IQR 1.4, 3.8). Table 1 demonstrates the distribution of lesions, 3-year OS, site-specific treatment information, and 3-year LC outcomes. Variables associated with local recurrence were lower biologically effective dose (assuming an α/β = 10, BEDGy10) (HR 0.89, 95% CI 0.80 – 0.99) and larger lesion size (HR 1.32, 95% CI 1.10 – 1.58), when analyzed as continuous variables at 10 Gy and 1 cm increments, respectively. Three-year LC was 81% for lesions receiving BEDGy10 ≥ 113 (the group median dose) versus 48% for BEDGy10 < 113 (p<0.01). The predominant first site of disease progression was distant metastasis outside of SBRT field (76%). SBRT is an effective means of obtaining long-term local control for patients with oligometastatic CRC, with some patients experiencing long-term survival. Higher SBRT doses were associated with better local control.Abstract SU_2_2015; Table 1OS, Treatment Characteristics, and Local control of CRC Metastasis Treated with SBRTSiteNDose (Gy)# fractionsBEDGy103-year LC3-year OS-85----46% (34% - 59%)All10750 (48, 54)4 (3, 5)113 (100, 151)72% (64% - 82%)-Lung4254 (48, 54)3 (3, 4)151 (105, 151)80% (68% - 93%)-Liver3460 (53, 60)5 (5, 5)132 (127, 151)70% (55% - 89%)-Bone1630 (26, 49)3 (3, 5)63 (60, 96)43% (24% - 79%)-Lymph node1050 (44, 50)5 (5, 5)100 (82, 100)100% (69% - 100%)-Other545 (36, 50)5 (5, 5)86 (61, 100)75% (43% - 100%)-* Continuous variables reported as the median (IQR), survival, and LC reported as percentage (95% CI). Open table in a new tab

Pulmonary extramedullary hematopoiesis, either in the lung parenchyma or the pleura, is an unusual sequela of marrow-depleting disorders that can precipitate symptomatic compromise of the respiratory system. In case reports of patients with pulmonary extramedullary hematopoiesis, low-dose external beam radiation therapy that targets the lungs has been shown to palliate respiratory symptoms and control pulmonary extramedullary hematopoiesis–associated pleural effusions with mixed results.1-11 Here, we present a case of symptomatic bilateral pulmonary extramedullary hematopoiesis-associated pleural effusions that were effectively managed with low-dose radiation therapy.

ECG-gated CT with coronary angiography (E-CTA) enables accurate delineation of cardiac substructures in time and space. We compared IMRT and IMPT to assess doses to the cardiac valves and left ventricle for patients treated with mediastinal radiation for lymphoma. Patients were prospectively enrolled in an institutional review board-approved, observational study. During simulation, patients underwent a CT scan using deep inspiratory breath hold and an E-CTA. A study-specific, multidisciplinary-designed, cardiac substructure contouring atlas was used to delineate the cardiac substructures in systole and diastole, which were then combined into PRVs. Target volumes were delineated using involved site radiotherapy. IMRT and IMPT plans were generated and normalized for 95% coverage of the CTV. Absolute differences between IMRT and IMPT plans were determined for V5-30Gy in increments of 5Gy and mean doses. Due to expected dose differences based on adenopathy site, each cardiac structure was analyzed independently. A paired T-test was used to compare differences between mean doses to substructures by modality. Twelve patients aged 14-53 years with lymphoma involving the mediastinum underwent comparative planning. The median prescription dose was 30 Gy in 15 fractions (r, 21-30 Gy). The median mean heart dose was 9.4Gy and 4.7 Gy for IMRT vs IMPT. The average mean, V5Gy, and V15 Gy to the left ventricle were all significantly less with IMPT. The average V25Gy was nearly significant as well (5.2 vs 2.8%, p=0.06). No individual patient had an increase in the dose to the LV with IMPT. The pulmonic valve was the only valve with a significant reduction in V30 Gy (27.2 vs 15.0%, p = 0.05). The majority of patients did not have any V30 Gy to the mitral or tricuspid valve with either modality. One patient did have an increase in the aortic valve V30 Gy by 10.6% with IMPT, and no significant benefit for the other valves with IMPT. The average mean dose to all valves was significantly lower IMPT. For patients with mediastinal lymphomas, IMPT reduced average doses to the left ventricle and cardiac valves when using E-CTA for cardiac substructure delineation.Abstract MO_20_2648; Table 1Substructure ParameterIMRT Mean (range)IMPT Mean (range)Paired T-TestLeft Ventricle Mean Dose [Gy]6.4 (0.6 – 14.6)2.1 (0.0 – 7.9)< 0.01 V5Gy [%]41.2 (0.0 – 91.9)10.8 (0.0 – 35.4)0.01 V15Gy [%]10.9 (0.0 – 32.3)5.2 (0.0 – 24.0)0.01 V25Gy [%]5.2 (0.0 - 26.1)2.8 (0.0 – 16.1)0.06Aortic Valve Mean Dose [Gy]16.1 (5.7 – 25.8)8.6 (0.8 – 17.2)<0.01 V30Gy [%]7.9 (0.0 – 36.9)3.6 (0.0 – 15.8)0.22Mitral Valve Mean Dose [Gy]10.5 (2.2 – 21.1)3.7 (0.0 – 10.6)< 0.01 V30Gy [%]3.1 (0.0 – 27.9)1.21 (0.0 – 12.2)0.20Pulmonic Valve Mean Dose [Gy]19.3 (8.0 – 30.1)14.1 (2.1 – 29.2)< 0.01 V30Gy [%]27.2 (0.0 – 71.5)15.0 (0.0-68.5)0.05Tricuspid Valve Mean Dose [Gy]8.6 (0.7 – 28.9)3.1 (0.0 – 20.2)< 0.01 V30Gy [%]6.5 (0.0 – 49.9)3.9 (0.0 – 39.0)0.18 Open table in a new tab

PURPOSE: Cholangiocarcinoma patients who are potential candidates for liver transplantation may be treated with high-dose-rate (HDR) brachytherapy using a minimally invasive nasobiliary catheter in an effort to escalate the radiotherapy dose to the tumor and maximize local control rates. This work describes the equipment, procedures, and quality assurance (QA) that enables successful administration. METHODS AND MATERIALS: This work describes the nasobiliary catheter placement, simulation, treatment planning, treatment delivery, and QA. In addition, a chart review was performed of all patients who received endoscopic retrograde cholangiopancreatography for HDR bile duct brachytherapy at our institution from 2007 to 2017. The review evaluated how many patients were treated and the number of patients who could not be treated because of anatomic and/or equipment limitations. RESULTS: From 2007 to 2017, 122 cholangiocarcinoma patients have been treated with HDR brachytherapy using a nasobiliary catheter. Three patients underwent catheter placement but did not receive brachytherapy treatment due to catheter migration between placement and treatment or because the HDR afterloader was unable to extend the source wire into the treatment site. Periodic QA is recommended for ensuring whether the HDR afterloader is capable of extending the source wire through an extensive and curved path. CONCLUSIONS: Intraluminal HDR brachytherapy with a nasobiliary catheter can be successfully administered. Procedures and QA are described for ensuring safety and overcoming technical challenges. (C) 2018 The Authors. Published by Elsevier Inc. on behalf of American Brachytherapy Society. This is an open access article under the CC BY-NC-ND license.

Radiation therapy (RT) improves event-free survival (EFS) for a subset of patients after systemic therapy for early stage classical Hodgkin (HL) and diffuse large B-cell lymphoma (DLBCL); however it is poorly understood which patients are most likely to benefit from the addition of RT. Host genetic background in immune function or chemotherapy metabolism genes may interact with treatment to impact outcome. In an exploratory study, we assessed whether single nucleotide polymorphisms (SNPs) from 27 candidate immune function and 20 chemotherapy metabolism genes predicted EFS in patients treated with chemotherapy (CT) alone , and for those SNPs associated with inferior EFS, whether this association was observed in patients treated with CT + RT. We used a prospective cohort study of patients with Stage I/II HL or DLBCL. Event-free survival (EFS) was defined as time from diagnosis to disease progression, retreatment, or death. 265 SNPs from our candidate genes were selected from HapMap using a standard tagging approach (r2 ≥0.80 and minor allele frequency ≥0.05) and included SNPs 5kb upstream and downstream from the gene. Genotyping was conducted using a custom panel. The most prevalent homozygous genotype was used as the reference, and each SNP was modeled as having a log-additive effect in a Cox regression model adjusted for age and lymphoma subtype. In Stage 1, we identified SNPs that were associated with inferior EFS (p<0.05) in patients treated with CT alone. In stage 2, SNPs found to be associated with inferior EFS in Stage 1 were analyzed for an association with EFS in patients treated with CT+RT. A total of 348 patients (138 HL; 210 DLBCL) were included in the analysis. The mean age was 54.5 years (range, 18-92) and 54% were male. Patients treated with CT only (n = 190) compared to CT+RT (n = 158) were more likely to have DLBCL (72 vs. 46%) and thus older (56 vs 45 years), but were similar on sex, performance status, and IPI/IPS risk grouping. In the CT only cohort, there were 80 events, while in the CT+RT cohort there were 29 events. In stage 1, 10 SNPs within the 7 candidate immune function genes and no chemotherapy metabolism genes were associated with inferior EFS in patients treated with CT only. In Stage 2, 7 of 10 SNPs associated with inferior EFS in Stage 1 were not associated with inferior EFS for patients treated with CT+RT, as displayed in the Table. In this preliminary analysis, germline variation in 5 immune function genes was associated with differing EFS for patients treated with CT alone vs those treated with CT+RT. Further exploration is needed to determine if the addition of radiation could mitigate inferior outcomes associated with these genes.Abstract 253; TableStage 1CT onlyStage 2CT+RTGeneSNPHRp-valueHRp-valueBCL2rs99551901.680.0050.980.946TBX21rs169470581.550.0081.000.995rs20741901.450.0400.880.663PTPN6rs107447242.270.0080.240.143C4BPArs48445731.560.0100.860.587rs45719691.450.0550.690.285PRF1rs109994232.440.0360.930.906 Open table in a new tab