62 Background: Patients with castrate-resistant prostate cancer (CRPC) with progressive disease are generally require a change/escalation in systemic therapy. For patients with limited ( ≤3) sites of progressive disease (oligoprogression), metastasis-directed therapy with stereotactic body radiation therapy (SBRT) may allow a longer interval before next line systemic therapy, but there is limited data describing this approach. Methods: This is a retrospective study of patients with oligoprogressive metastatic CRPC (omCRPC) treated with SBRT at a single center between 2011-2022. The primary endpoint was time to next systemic therapy (TTNST) after SBRT. Secondary endpoints included overall survival (OS) after SBRT and TTNST stratified by presence of untreated non-progressing metastases. Results: Thirty-two patients with omCRPC received SBRT to 38 metastases. Patients had a median age of 72.5 years (range 50.6-84.3) and median PSA 6.85 ng/mL (range 0.39-922.0) at time of SBRT. The majority had an ECOG of 1-2 (29 patients, 90.6%) and metastases detected on conventional CT and/or bone scans (26 patients, 81.3%). The most commonly utilized SBRT regimen was 3000 cGy in 5 fractions (18 metastases, 47.4%) (Table). Sixteen patients were treated to all known sites of disease, whereas 16 patients received SBRT to oligoprogressive metastases but had at least one untreated non-progressing metastasis at the time of SBRT. Of 32 patients, 23 (65.7%) received SBRT to bone only, 3 (9.4%) to lymph node (LN) only, and 6 (18.8%) to other sites (pelvic tumor, n=2; pelvic tumor + LN, n =1; LN + bone, n=1; dura + bone, n=1; liver, n=1). Patients had received a median of 1.0 prior line of androgen receptor signaling inhibitors and were predominantly (26 patients, 81.3%) chemotherapy naïve. Following SBRT, the median TTNST was 10.1 months and median OS was 41.3 months. For patients with 0 versus ≥1 untreated non-progressing metastasis, TTNST was 11.3 versus 8.7 months, respectively (HR 0.67, 95% CI 0.33-1.36, logrank p=0.24). There were no grade ≥3 toxicities due to SBRT. Conclusions: In this cohort, patients with omCRPC treated with SBRT delayed the next line of systemic therapy for a median of 10.1 months. SBRT in patients with omCRPC may delay initiation of next line systemic therapy in well selected patients, including those with ≥1 untreated non-progressing metastases. [Table: see text]

Purpose Limited structured educational programs are available for the continued professional development of radiation oncology nurses. In this study, we evaluated a pilot curriculum focusing on clinical workflow and toxicity management for radiation oncology nurses at a single university-affiliated medical center network. Methods and Materials Based on a previous multi-institutional needs assessment, a targeted curriculum on clinical workflow and toxicity management was developed, including didactic lectures, written disease-specific toxicity management guidelines, and standardized medication/laboratory order preference lists in the electronic health record. An anonymized survey was circulated to all participants pre- and postcurriculum. The survey was composed of Likert-type subjective questions and 11 objective knowledge-based questions (KBQs). Paired Likert-type data were analyzed using Wilcoxon signed ranks test. Objective question data were compared with the McNamar's mid P test. Results Thirteen nurses participated in the pilot curriculum and 100% completed pre- and post curriculum surveys. After the didactics, nurses reported a significant increase in their understanding of the responsibilities of a nurse and overall process of care and their ability to explain computed tomography simulation, as well as their ability to assess, manage, and grade radiation-related toxicities (P < .01). There was significant improvement in the percent of correct answers on objective KBQs from a baseline of 52% to 80% after the curriculum (P < .01). Qualitatively, 70% (9/13) of nurses rated the curriculum as "extremely useful" and 30% (4/13) as "quite useful." Conclusions Our pilot curriculum using a combination of in-person formal didactics, toxicity management guidelines, and electronic health record based order preference lists was well-received and showed promising results on KBQ assessment. This work may be used to guide the development of larger curricula for nurse onboarding and continuing education in a multicenter setting.

Table of Mutant Allele Fractions

Detailed Individual Characteristics of 49 Enrolled Patients

The purpose of this report is to present the implementation of a process for after-hours radiation treatment (RT) utilizing remote treatment planning based on optimized diagnostic computed tomography (CT) scans for the urgent palliative treatment of inpatients. A standardized operating procedure was developed by an interprofessional panel to improve the quality of after-hours RT and minimize the risk of treatment errors. A new diagnostic CT protocol was created that could be performed after-hours on hospital scanners and would ensure a reproducible patient position and adequate field of view. An on-call structure for dosimetry staff was created utilizing remote treatment planning. The optimized CT protocol was developed in collaboration with the radiology department, and a novel order set was created in the electronic health system. The clinical workflow begins with the radiation oncologist notifying the on-call team (therapist, dosimetrist, and physicist) and obtaining an optimized diagnostic CT scan on a hospital-based scanner. The dosimetrist remotely creates a plan; the physicist checks the plan; and the patient is treated. Plans are intentionally simple (parallel opposed fields, symmetric jaws) to expedite care and reduce the risk of error. Education on the new process was provided for all relevant staff. Our process was successfully implemented with the use of an optimized CT protocol and remote treatment planning. This approach has the potential to improve the quality and safety of emergent after-hours RT by better approximating the normal process of care.

PURPOSE:Nurses in the radiation oncology (RO) clinic have a critical role in the management of patients receiving radiation therapy. However, limited data exist regarding the exposure of nurses to RO during training and the current educational needs of practicing RO nurses. This study assesses nurses' prior RO education, participation in national training efforts, and perceived educational needs. METHODS AND MATERIALS:A web-based survey using a 5-point Likert-type scale was distributed to RO nurses at 3 academic medical centers. Questions focused on prior education experiences, clinical areas of strength/weakness, and perceived value of future educational interventions. Likert-type scores are reported as median (interquartile range), and a Kruskal-Wallis test was conducted to assess for significant differences in responses. RESULTS:The survey response rate was 39 of 54 (72%). Respondents were 90% female and trained at 30 nursing schools in 17 states. Only 5% of nurses reported a curriculum in nursing school with RO content, and nearly all (97%) received their RO education on the job. Forty-one percent of nurses completed the Oncology Nursing Society radiation therapy certificate course, and only 5% completed the American Society for Radiation Oncology nursing module. Nurses felt most confident in the overall management of patients with breast (4 [3-4]), prostate (4 [3-5]), and central nervous system (4 [3-4]) cancers and least confident for lymphoma (3 [2-4]), gynecologic (3 [2-4]), and head and neck cancers (3 [2-4]; P < .01). Nurses rated didactic lectures from physicians (5 [3-5]), shadowing RO residents (4 [3-5]), and working with simulation therapists (4 [3-5]) as valuable components to include in a training curriculum (P = .08). CONCLUSIONS:Nursing school exposure to RO is limited, and only a minority of RO nurses complete RO-specific training or certification available from national organizations. This study identifies several areas of perceived clinical nursing strengths and weaknesses that can be used to inform the design of future RO nursing educational programs.

Purpose Automatic detection and identification of setup devices, using a deep convolutional neural network (CNN) for real-time multiclass object detection, has the potential to reduce errors in the treatment delivery process by avoiding documentation errors. Methods A database of the setup device photos from the most recent 1200 patients treated at our institution was downloaded from the record and verify (R&V) system along with the corresponding setup notes. Images were manually labeled with bounding boxes of each device. A real-time object detection CNN using the "you only look once" (YOLOv2) architecture was trained using transfer learning of a pretrained CNN (ResNet50). The CNN was trained to detect and identify 11 of the most common treatment accessories used at our institution. Results Using transfer learning of a CNN for multiclass object detection, we are able to automatically detect and identify setup devices in photographs with an accuracy of 96%. Conclusions Automation in radiation oncology has the potential to reduce risk. Automatic detection of setup devices is possible using a CNN and transfer learning. This work shows both the value of incident learning systems (ILS) in practice knowledge dissemination, and shows how automation of clinical processes and less reliance on manual documentation has the potential for risk reduction in radiation oncology treatments.

The NCCN Guidelines for Uveal Melanoma include recommendations for staging, treatment, and follow-up of patients diagnosed with uveal melanoma of the choroid or ciliary body. In addition, because distinguishing between uveal melanoma and benign uveal nevi is in some cases difficult, these guidelines also contain recommendations for workup of patients with suspicious pigmented uveal lesions, to clarify the tests needed to distinguish between those who should have further workup and treatment for uveal melanoma versus those with uncertain diagnosis and low risk who should to be followed and later reevaluated. These NCCN Guidelines Insights describe recommendations for treatment of newly diagnosed nonmetastatic uveal melanoma in patients who have already undergone a complete workup.

INTRODUCTION AND OBJECTIVE: With the rapid utilization of new advanced technology for localized prostate cancer (PCa), we performed a national survey of radiation oncologists (RO) and urologists (URO) to assess the perceptions on outcomes for robotic-assisted radical prostatectomy (RARP) and proton radiotherapy (PRT) compared with open radical prostatectomy (ORP) and intensity-modulated radiation therapy (IMRT). METHODS: In 2012, we surveyed 1,366 PCa specialists on whether RARP and PRT provided better cancer control, treatment-related toxicities, and quality of life (QOL) relative to conventional treatments. Pearson’s chi-square test and multivariate logistic regression were used to test for the association between physician characteristics and perceptions of PRT versus IMRT and RARP versus ORP. RESULTS: Overall, 717 (52%) respondents completed the survey. Few specialists believed that PRT was superior to IMRT for cancer control (2.1%), urinary incontinence (3.9%), or sexual dysfunction (4.5%). RO were more likely than URO to perceive PRT had less treatment-related rectal toxicity (28.5% vs. 15.5; adjusted OR: 2.49, p<0.001), risks for hip fracture (28.5% vs. 4.5% adjusted OR: 9.43, p<0.001), and secondary malignancies (28.5% vs. 11.2%; adjusted OR: 4.65, p<0.001). A third of respondents agreed that RARP conferred less urinary incontinence (32.9%) and sexual dysfunction (30.0%) relative to ORP, but with no differences in cancer control. Respondents with access to robotic surgery in their practice believed RARP superior to ORP in having less urinary incontinence (adjusted OR: 2.71; p<0.001) and sexual dysfunction (adjusted OR: 3.21; p<0.001) compared to those without access. CONCLUSIONS: RO and URO largely view the benefits of PRT and RARP from less treatment-related toxicity and QOL implications for patients with localized PCa. However, neither RO and URO considered either newer treatments conferring better cancer control. Source of Funding: This study was supported by a Robert Derzon Award, Informed Medical Decisions Foundation and a Career Development Award for Dr. Simon Kim from the Conquer Cancer Foundation and American Society of Clinical Oncology (ASCO).

Purpose: The significance of radiation dose to the host immune system during the treatment of stage III non-small cell lung cancer (NSCLC) is unknown, but higher doses were associated with worse tumor control and overall survival (OS) in a secondary analysis of RTOG 0617. In this study, we sought to assess the impact of the estimated dose of radiation to immune cells (EDRIC) on cancer-specific outcomes in an independent cohort of patients treated at our institution. Methods and Materials: We retrospectively identified 117 patients with stage III NSCLC treated with definitive fractionated radiation from 2004 to 2017 at a single academic center (median dose of 60 Gy; 60% underwent intensity modulated radiation therapy and 92% received concurrent platinum-based chemotherapy). EDRIC was calculated as a function of the number of radiation fractions and mean doses to the lung, heart, and remaining body based on a model developed by Jin et al. Results: Median follow-up was 16 months with 77% of patients followed until death. In the entire population, 5-year OS was 11.2% with a median survival of 17.3 months. Median EDRIC for the entire cohort was 6.1 Gy (range, 2.5-10.0 Gy). A higher EDRIC was correlated with greater risk of grade >= 3 lymphopenia (P = .004). On multivariate analysis including total prescription radiation dose, planning target volume, and chemotherapy utilization, EDRIC was independently associated with OS (hazard ratio [HR] 1.17, P =. 03), local progressionefree survival (HR 1.17, P = .02), and disease-free survival (HR 1.15, P = .04). The median OS for patients with an EDRIC above 7.3 Gy (fourth quartile) and below 5.1 Gy (first quartile) was 14.3 and 28.2 months, respectively. Conclusions: Higher doses of radiation to the immune system were associated with tumor progression and death after the definitive treatment of stage III NSCLC. Tailoring radiation therapy to spare the immune system may be an important future direction to improve outcomes in this population. (C) 2019 Elsevier Inc. All rights reserved.

Radiation oncology (RO) nurses have an important role in the management of patients receiving radiotherapy. However, limited data exist regarding the exposure to RO in nursing schools and the educational needs of practicing RO nurses. This study aims to assess nurses’ prior RO educational experiences and characterize field-specific perceived educational needs. A web-based survey utilizing a 5-point Likert-type scale (5 “Extremely confident,” 4 “Quite confident,” 3 “Moderately confident,” 2 “Slightly confident,” and 1 “Not at all confident”) was developed by an expert panel of nurses/physicians and distributed via email to RO nurses at three academic medical centers. Questions focused on prior education experiences, clinical areas of strength/weakness, and perceived value of future educational interventions were asked. Likert-type scores are reported as median [interquartile range]. RO nurses at 3 academic medical centers were surveyed with 39/54 (72%) responding. Respondents were 90% female and trained at 30 nursing schools in 17 US states. 56% had >10 years of post-nursing school experience. However, only 21% had >10 years of experience with RO patients and 39% had 1-4 years of RO experience. Most nurses (92%) did not have an affiliated RO department at their nursing school, only 5% had RO curriculum content and 0% had a mandatory RO clinical experience. Nearly all nurses (97%) received the majority of their RO education on the job. 41% of nurses completed the Oncology Nursing Society/Oncology Nursing Certification Corporation (ONS/ONCC) radiation therapy certificate course. However, only 5% completed the American Society for Radiation Oncology (ASTRO) nursing module. 85% of nurses felt most comfortable taking care of adult patients. Nurses felt most confident in managing patients with breast 4[3-4], prostate 4[3-5], and CNS 4[3-4] cancers and least confident caring for lymphoma 3[1.75-4], gynecologic 3[2-4], head & neck 3[2-4], and GI 3[2.75-4] cancers. Nurses were most confident managing side effects for breast (61%) and prostate cancer (58%) patients and least confident in managing side effects for lymphoma (11%) and gynecologic cancer (32%) patients. Most nurses thought it would be extremely useful to receive didactic lectures from residents/physicians 5[3-5] and to spend time working with a radiation oncology resident 4[3-5] as part of their onboarding experience. Exposure to RO in nursing schools is limited and only a minority of RO nurses complete additional field-specific training. Integration of RO-related education programs is needed during RO nurse onboarding with encouragement of completion of national certification programs to help improve the quality of RO patient management. This study also identifies several areas of perceived clinical nursing strength and weakness. The results can be used to inform the design of future RO nursing curricula.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cutaneous melanoma have been significantly revised over the past few years in response to emerging data on immune checkpoint inhibitor therapies and BRAF-targeted therapy. This article summarizes the data and rationale supporting extensive changes to the recommendations for systemic therapy as adjuvant treatment of resected disease and as treatment of unresectable or distant metastatic disease.

This case looks at an otherwise healthy 59-year-old man who was recently diagnosed with clinical stage IVB prostate adenocarcinoma. What is the most appropriate management for this patient?

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Cutaneous melanoma have been significantly revised over the past few years in response to emerging data on immune checkpoint inhibitor therapies and BRAF-targeted therapy. This article summarizes the data and rationale supporting extensive changes to the recommendations for systemic therapy as adjuvant treatment of resected disease and as treatment of unresectable or distant metastatic disease.

We are grateful for the opportunity to provide commentary on the recent work by Fossati et al ., entitled “Impact of Early Salvage Radiation Therapy in Patients with Persistently Elevated or Rising Prostate-specific Antigen After Radical Prostatectomy” (1). The optimal post-operative management of patients with prostate cancer who undergo radical prostatectomy (RP) is unclear. In general, there are two strategies for approaching radiotherapy. Adjuvant radiation therapy (ART) typically refers to post-operative radiation in the setting of high risk pathologic features but with an undetectable post-prostatectomy PSA, where the presence of residual prostate cancer is suspected but unknown. In this setting, radiation is typically delivered within a few months of surgery once there has been adequate recovery of urinary function. In contrast, salvage radiation therapy (SRT) refers to post-operative radiation in the setting of a rising or persistently detectable PSA, indicative of active prostate cancer and may be delivered several years after the initial RP (2). However, it is important to note that these definitions lack consensus.

Purpose: Tumor hypoxia correlates with treatment failure in patients undergoing conventional radiation therapy. However, no published studies have investigated tumor hypoxia in patients undergoing stereotactic body radiation therapy (SBRT). We aimed to noninvasively quantify the tumor hypoxic volume (HV) in non-small cell lung cancer (NSCLC) tumors to elucidate the potential role of tumor vascular response and re-oxygenation at high single doses. Methods and Materials: Six SBRT-eligible patients with NSCLC tumors >1 cm were prospectively enrolled in an institutional review boardeapproved study. Dynamic positron emission tomography images were acquired at 0 to 120 minutes, 150 to 180 minutes, and 210 to 240 minutes after injection of F-18-fluoromisonidazole. Serial imaging was performed prior to delivery of 18 Gy and at approximately 48 hours and approximately 96 hours after SBRT. Tumor HVs were quantified using the tumor-to-blood ratio (>1.2) and rate of tracer influx (>0.0015 mL.min.cm(-3)). Results: An elevated and in some cases persistent level of tumor hypoxia was observed in 3 of 6 patients. Two patients exhibited no detectable baseline tumor hypoxia, and 1 patient with high baseline hypoxia only completed 1 imaging session. On the basis of the tumor-to-blood ratio, in the remaining 3 patients, tumor HVs increased on day 2 after 18 Gy and then showed variable responses on day 4. In the 3 of 6 patients with detectable hypoxia at baseline, baseline tumor HVs ranged between 17% and 24% (mean, 21%), and HVs on days 2 and 4 ranged between 33% and 45% (mean, 40%) and between 18% and 42% (mean, 28%), respectively. Conclusions: High single doses of radiation delivered as part of SBRT may induce an elevated and in some cases persistent state of tumor hypoxia in NSCLC tumors. Hypoxia imaging with F-18-fluoromisonidazole positron emission tomography should be used in a larger cohort of NSCLC patients to determine whether elevated tumor hypoxia is predictive of treatment failure in SBRT. (C) 2018 Elsevier Inc. All rights reserved.

Introduction: Patients with brain metastases (BMs) arising from EGFR-mutated and anaplastic lymphoma kinase gene (ALK)-rearranged NSCLC have a favorable prognosis compared with patients with non-oncogene-addicted NSCLC, emphasizing the importance of minimizing toxicities such as the cognitive sequelae of whole brain radiation therapy (WBRT). Although radiosurgery without WBRT is the preferred strategy for one to three BMs, this paradigm remains controversial for patients with multiple BMs. Methods: We reviewed the cases of patients with EGFR-mutated and ALK-rearranged NSCLC presenting to our cancer center between 2008 and 2017 and included only patients receiving treatment to four or more BMs in a single radiosurgery session. Results: We identified 35 patients with a median follow-up of 4.1 years. The maximum number of BMs treated in a single radiosurgery session ranged from-four to 26 (median number of BM treated per radiosurgery course: 6), and in total over all courses the number ranged from four to 47 (median: 10). The median survival was 3.0 years (4.2 for ALK-rearranged SCLC; 2.4 for EGFR-mutated NSCLC) from the diagnosis of BM, and survival was comparable regardless of number of radiosurgery courses, number of BMs treated in total, or number of BMs treated in a single radiosurgery session. The mean hippocampal and whole-brain doses were exceedingly low even for patients receiving treatment to more than 10 BMs (1.2 and 0.8 Gy, respectively). Radiosurgery was well tolerated overall and the 5-year rate of freedom from neurologic death was 84%. The 5-year rate of freedom from WBRT was 97%. Conclusions: Radiosurgery for multiple BMs is controversial, yet patients with EGFR-mutated and ALK-rearranged NSCLC may be uniquely suited to benefit from this approach. These results support single and multiple courses of radiosurgery without WBRT for patients with oncogene-addicted NSCLC with four or more BMs. (C) 2017 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

OBJECTIVE:The objective of this study is to determine the frequency of clinically significant cancer (CSC) in Prostate Imaging Reporting and Data System (PI-RADS) category 3 (equivocal) lesions prospectively identified on multiparametric prostate MRI and to identify risk factors (RFs) for CSC that may aid in decision making.MATERIALS AND METHODS:Between January 2015 and July 2016, a total of 977 consecutively seen men underwent multiparametric prostate MRI, and 342 underwent MRI-ultrasound (US) fusion targeted biopsy. A total of 474 lesions were retrospectively reviewed, and 111 were scored as PI-RADS category 3 and were visualized using a 3-T MRI scanner. Multiparametric prostate MR images were prospectively interpreted by body subspecialty radiologists trained to use PI-RADS version 2. CSC was defined as a Gleason score of at least 7 on targeted biopsy. A multivariate logistic regression model was constructed to identify the RFs associated with CSC.RESULTS:Of the 111 PI-RADS category 3 lesions, 81 (73.0%) were benign, 11 (9.9%) were clinically insignificant (Gleason score, 6), and 19 (17.1%) were clinically significant. On multivariate analysis, three RFs were identified as significant predictors of CSC: older patient age (odds ratio [OR], 1.13; p = 0.002), smaller prostate volume (OR, 0.94; p = 0.008), and abnormal digital rectal examination (DRE) findings (OR, 3.92; p = 0.03). For PI-RADS category 3 lesions associated with zero, one, two, or three RFs, the risk of CSC was 4%, 16%, 62%, and 100%, respectively. PI-RADS category 3 lesions for which two or more RFs were noted (e.g., age ≥ 70 years, gland size ≤ 36 mL, or abnormal DRE findings) had a CSC detection rate of 67% with a sensitivity of 53%, a specificity of 95%, a positive predictive value of 67%, and a negative predictive value of 91%.CONCLUSION:Incorporating clinical parameters into risk stratification algorithms may improve the ability to detect clinically significant disease among PI-RADS category 3 lesions and may aid in the decision to perform biopsy.