Habitat escalated adaptive therapy (HEAT): a phase 2 trial utilizing radiomic habitat-directed and genomic-adjusted radiation dose (GARD) optimization for high-grade soft tissue sarcoma

BACKGROUND

Soft tissue sarcomas (STS), have significant inter- and intra-tumoral heterogeneity, with poor response to standard neoadjuvant radiotherapy (RT). Achieving a favorable pathologic response (FPR ≥ 95%) from RT is associated with improved patient outcome. Genomic adjusted radiation dose (GARD), a radiation-specific metric that quantifies the expected RT treatment effect as a function of tumor dose and genomics, proposed that STS is significantly underdosed. STS have significant radiomic heterogeneity, where radiomic habitats can delineate regions of intra-tumoral hypoxia and radioresistance. We designed a novel clinical trial, Habitat Escalated Adaptive Therapy (HEAT), utilizing radiomic habitats to identify areas of radioresistance within the tumor and targeting them with GARD-optimized doses, to improve FPR in high-grade STS.

METHODS

Phase 2 non-randomized single-arm clinical trial includes non-metastatic, resectable high-grade STS patients. Pre-treatment multiparametric MRIs (mpMRI) delineate three distinct intra-tumoral habitats based on apparent diffusion coefficient (ADC) and dynamic contrast enhanced (DCE) sequences. GARD estimates that simultaneous integrated boost (SIB) doses of 70 and 60 Gy in 25 fractions to the highest and intermediate radioresistant habitats, while the remaining volume receives standard 50 Gy, would lead to a > 3 fold FPR increase to 24%. Pre-treatment CT guided biopsies of each habitat along with clip placement will be performed for pathologic evaluation, future genomic studies, and response assessment. An mpMRI taken between weeks two and three of treatment will be used for biological plan adaptation to account for tumor response, in addition to an mpMRI after the completion of radiotherapy in addition to pathologic response, toxicity, radiomic response, disease control, and survival will be evaluated as secondary endpoints. Furthermore, liquid biopsy will be performed with mpMRI for future ancillary studies.

DISCUSSION

This is the first clinical trial to test a novel genomic-based RT dose optimization (GARD) and to utilize radiomic habitats to identify and target radioresistance regions, as a strategy to improve the outcome of RT-treated STS patients. Its success could usher in a new phase in radiation oncology, integrating genomic and radiomic insights into clinical practice and trial designs, and may reveal new radiomic and genomic biomarkers, refining personalized treatment strategies for STS.

TRIAL REGISTRATION

NCT05301283.

TRIAL STATUS

The trial started recruitment on March 17, 2022.

Diagnostic Delay in HPV-Related Oropharyngeal Squamous Cell Carcinoma

Introduction  Human papillomavirus-related (HPV + ) oropharyngeal squamous cell carcinoma (OPSCC) is increasing in incidence and presents diagnostic challenges given its unique clinical presentation. Objective  The purpose of the present study is to characterize the impact of the unique clinical presentation of HPV-related OPSCC on delays in diagnosis. Methods  Retrospective review of presenting symptoms and clinical characteristics of 284 patients with OPSCC treated from 2002-2014. Delay in diagnosis was defined as the presence of any of the following: multiple non-diagnostic fine needle aspirate (FNA) biopsies; two or more courses of antibiotic therapy; surgery with incorrect preoperative diagnosis; evaluation by an otolaryngologist without further workup; or surgery without definitive postoperative diagnosis. Results  p16+ tumors demonstrated a distinct clinical presentation that more commonly involved a neck mass (85.1% versus 57.3% of p16-; p  < 0.001) and less frequently included odynophagia (24.6% versus 51.7% of p16-; p  < 0.001). Patients who experienced diagnostic delay were more likely to have p16+ tumors (77.7% delayed versus 62.8% not delayed; p  = 0.006). p16+ primary tumors were more likely to be undetectable by physical examination of the head and neck including flexible laryngoscopy (19.0% versus 6.7% of p16-; p  = 0.007) and more frequently associated with nondiagnostic FNA biopsies of a cervical nodal mass (11.8% versus 3.4% of p16-, p  = 0.03). Conclusions  Compared with non-HPV related OPSCC, the unique clinical presentation and characteristics of HPV+ OPSCC are associated with an increased incidence of diagnostic delay. Targeted education of appropriate care providers may improve time to diagnosis and treatment.

Outcomes of Moderately Dose Escalated Hypofractionated Chemoradiation for Pancreatic Cancer

PURPOSE/OBJECTIVE(S)

A modestly hypofractionated course of chemoradiation (CRT) consisting of 36 Gy/15 fractions (F) concurrent with gemcitabine used in PREOPANC and phase II trials has become increasingly common for the treatment of borderline resectable (BR) and locally advanced (LA) pancreatic cancer (PC). Achieving an R0 resection remains a key prognostic factor in PC. We tested whether escalating dose beyond standard dosing (SD) of 36-39 Gy/15 F (or 50-54 Gy/25-30 F) would improve R0 resection rates and outcomes while respecting nearby organs at risk.

MATERIALS/METHODS

This was a retrospective analysis of consecutive patients at our institution from 2012-2022 with BR/LA PC treated with moderate dose escalated (MDE) (45 Gy/15 F, N = 45) or SD (36-39 Gy/15 F, N = 68 or 50-54 Gy/25-30 F, N = 25) CRT. For MDE, a 5 mm expansion from the duodenum, small bowel, and stomach was created (GI_PRV); PTV was cropped from this structure and prescribed 45 Gy/15 F. The primary endpoint was R0 resection rate with secondary endpoints of cumulative incidence of local progression (LP, recurrence after surgery/imaging progression if no surgery) with death as a competing risk (LP after occurrence of distant metastasis [DM] were still captured), cumulative incidence of DM, and overall survival (OS). Univariable and multivariable competing risks regression analyses were performed to determine the association between baseline covariates and LP.

RESULTS

We identified 45 patients treated with MDE and 93 treated with SD. Most patients presented with BR disease (55.6% MDE; 54.8% SD) and received neoadjuvant chemotherapy with FOLFIRINOX (98% MDE; 99% SD). All patients in the MDE group and 99% in the SD group received concurrent chemotherapy with gemcitabine used most often (96% MDE; 77% SD). Median follow-up was 17 m (IQR 13-27 m). Surgical resection rates were similar between groups (33.3% MDE vs. 39.8% SD, p = 0.46). Amongst patients that had surgery, R0 resection rates were non-significantly higher in the MDE group (73.3% vs. 47.4%, p = 0.09). Cumulative incidence of LP at 18 m was significantly lower in the MDE group (9.0% vs. 24.8%, p = 0.04). No difference in rates of DM (51.2% MDE vs. 59.6% SD, p = 0.92) or OS at 18 m (53.9% vs. 53.6%, p = 0.89) were observed. On multivariable analysis, MDE (HR = 0.39, p = 0.03) and pancreatic head location (HR = 0.51, p = 0.04) were the only factors independently associated with LP. Rates of grade 2+ gastrointestinal toxicity during CRT (20% MDE vs. 20.9% SD, p = 0.91) and ≤90 days of completing CRT (11.6% MDE vs. 14.8%, p = 0.62) were similar between groups, as were rates of grade 3+ hematologic toxicity (52.3% MDE vs. 41.3% SD, p = 0.23).

CONCLUSION

In this single institutional study, we found MDE is a simple, safe, and effective strategy associated with improved local control, higher R0 resection rates, and similar toxicity to SD CRT for patients with BR/LA PC. Further prospective data is needed to clarify the role of dose-escalated RT in the management of this lethal malignancy.

Teaching Trainees to be Effective Mentors: A Needs-Based Assessment in Radiation Oncology

PURPOSE/OBJECTIVE(S)

Mentorship plays a critical role in the training and career development of medical trainees. Teaching-the-teacher workshops for residents translate to higher long-term job satisfaction and improved patient communication skills. Further, near-peer mentorship has been associated with increased job satisfaction and patient care experience. Resident-as-mentors can add benefit to the mentorship networks of students, particularly in resource-limited environments, while benefiting residents' own mentorship relations and career satisfaction. We hypothesized that residents would desire to be a mentor, but would lack specific skills needed for effective mentoring of students in radiation oncology.

MATERIALS/METHODS

A multi-institution, cross-sectional study was conducted among residents in the Radiation Oncology Education Collaborative Study Group (ROECSG) Graduate Medical Education working group from 06/2022-10/2022. Participants completed the Mentorship Competency Assessment (MCA), a validated 26-item questionnaire, scored on a Likert scale from 0-7 (0: most unprepared with mentorship skill, 7: most prepared with mentorship skill). The primary endpoint was the average score in individual mentorship skills among participants. Kruskal-Wallis test assessed associations between total MCA score (range 0-182) and demographics.

RESULTS

A total of 36 of 39 participants (92% response rate) responded. A majority were male (58%), from a residency size >10 (75%), and P Gy-2/3 (52%). Most had no formal training in teaching (86%) or mentorship (89%). Many believed they would be a good mentor to students on a rotation (89%), but most felt they would benefit from a formal mentorship program (92%). From the MCA, the mentorship skills residents felt most unprepared for were: coordinating effectively with other mentors (3.4/7), helping mentees acquire resources (3.6/7), negotiating a path to professional independence with mentees (3.6/7), helping mentees network effectively (3.7/7), and working with mentees to set clear expectations of the mentoring relationship (3.9/7). The mentorship skills residents felt most prepared for were: acknowledging mentees' professional contributions (5.6/7), establishing a relationship based on trust (5.6/7), active listening (5.5/7), building mentees' confidence (4.9/7), and working effectively with mentees with personal backgrounds differing from one's own (4.8/7). Higher MCA scores were associated with former training in mentorship (p = 0.0143), and a trend for former training in teaching (p = 0.0525), but was not associated with sex (p = 0.5986), residency size (p = 0.1415), or P Gy-year (p = 0.9747).

CONCLUSION

Residents are interested in mentorship training and report unpreparedness in several important skills. Future work should focus on formal training and assessment of mentoring skills for residents.

Patient-Reported Cognitive Outcomes and Survival after Stereotactic Radiosurgery for 15 or More Brain Metastases

PURPOSE/OBJECTIVE(S)

Overall survival (OS) in metastatic cancer patients has been improving with continued advancements, necessitating greater attention to treatment related toxicities. Patients with ≥ 15 brain metastases (BM) continue to be treated with whole brain radiation therapy (WBRT), despite poor neurocognitive outcomes. We analyzed our institutional experience of treating these patients with stereotactic radiosurgery (SRS), with the aim of evaluating safety, cognitive outcomes, and survival metrics.

MATERIALS/METHODS

Patients who received SRS for ≥ 15 BMs in 1-5 fractions from 2014-2022 using the previously described single isocenter multi-target technique were included. Cognitive outcomes were objectively evaluated using serial Patient-Reported Outcome Measurement Information System (PROMIS) scores. Kaplan-Meier method was used for survival analysis and log-rank test was used for intergroup comparisons.

RESULTS

A total of 118 patients underwent 124 courses of LINAC-based SRS. The mean and median number of lesions treated per patient was 24.8 and 20, respectively (range 15 - 94). Most common primary histologies were lung (47.6%), melanoma (21.0%), and breast (14.5%). The median SRS dose was 24 Gy (range 18 - 30 Gy) with 87.9% receiving 3 fraction SRS. At the time of SRS, 19.4% patients had received prior WBRT and 24.2% had received at least one prior SRS course. The rate of any grade radiation necrosis (RN) and ≥ grade 3 RN were 15.3% and 3.2% respectively. New onset seizures were seen in 2.4%, alopecia in 2.4%, and subjective cognitive decline in 4% of patients. Median follow-up by reverse Kaplan-Meier method was 17.8 months (m). Cognitive data was available for 38 patients. Mean PROMIS scores at baseline, 3m, 6m and 9m after SRS were 32.0, 31.6, 30.4 and 28.7 out of 40, respectively. When longitudinal trends were available, 25 of 31 patients had a stable or improved PROMIS score. The 12m local control was 97.6%. Cumulative incidence of distant intracranial failure was 79.2%. One year freedom from neurological death, leptomeningeal disease, and salvage WBRT were 85.6%, 87.6% and 71.7% respectively. Median OS from brain metastases diagnosis was 11.3m (95% CI 7.2m - 15.3m) overall, while it was 9.2m (6.5 - 11.8m) after excluding patients who had prior WBRT or SRS (n = 79). One-year survival was 40% from diagnosis and 38.7% from SRS. On Cox regression analysis, prior WBRT (p = 0.002), higher KPS (p = 0.050), systemic therapy after SRS (p<0.001), and controlled extracranial disease (p = 0.007) predicted for improved OS.

CONCLUSION

We present here the largest study evaluating SRS for patients with ≥ 15 BMs. We found that SRS was safe, had favorable cognitive outcomes, and comparable survival outcomes to contemporary studies evaluating WBRT in this patient population. Treatment-naïve patients had a median survival of > 6 months, long enough to benefit from cognitive sparing with SRS. Our study supports further randomized studies comparing SRS and memory avoidance WBRT approaches for patients with ≥ 15 BMs.

Bridging Radiotherapy Prior to Chimeric Antigen Receptor T-Cell Therapy for B-Cell Lymphomas: An ILROG Multi-Institutional Study

PURPOSE/OBJECTIVE(S)

To report an ILROG multi-institutional analysis of bridging radiotherapy (BRT) prior to CD19-targeting chimeric antigen receptor T-cell (CAR T) therapy for relapsed/refractory aggressive B-cell lymphomas (BCL).

MATERIALS/METHODS

Weretrospectively reviewed 115 patients (pts) with diffuse large BCL (n = 101, 88%), primary mediastinal BCL (n = 11, 10%), mantle cell lymphoma (n = 2, 2%), and T-cell/histiocyte rich large BCL (n = 1, 1%) who received BRT prior to commercial CAR T from 2018-2020 across 6 institutions. BRT toxicities were graded per CTCAE v5.0, cytokine release syndrome (CRS) per ASTCT, and immune effector cell-associated neurotoxicity syndrome (ICANS) per either ASTCT or CTCAE v5.0. Progression-free survival (PFS) and overall survival (OS), measured from CAR T infusion, were estimated using the Kaplan-Meier method. PFS was modeled using Cox regression with stepwise variable selection.

RESULTS

BRTwas given prior to axicabtagene ciloleucel (axi-cel; n = 82, 71%), tisagenlecleucel (tisa-cel; n = 31, 27%), or brexucabtagene autoleucel (n = 2, 2%). Median age was 62 years with median of two prior lines of therapy. Most pts had advanced stage III/IV disease at leukapheresis (n = 87, 76%), elevated pre-leukapheresis LDH (n = 73, 63%), and bulky disease (n = 55, 50%) (1 lesion ≥7.5 cm). 78 pts (68%) had extranodal disease, 12 (10%) had central nervous system (CNS) involvement, and 36 (31%) had bone involvement. Systemic bridging therapy was given to 42 pts (37%). Median intervals from leukapheresis to BRT start and from BRT completion to CAR T infusion were 5 days (IQR -6, 11) and 12 days (IQR 9, 23), respectively. BRT was delivered to 163 total sites; most commonly the abdomen/pelvis (n = 58, 50%), head/neck (n = 34, 30%), thorax (n = 20, 17%), extremity/soft tissue (n = 20, 17%), and CNS (n = 13, 11%). Median biologically effective dose was 31.3 Gy (IQR 24, 39). Most common regimen was 30 Gy in 10 fractions (n = 27, 17%). 40 pts (35%) received comprehensive BRT (to all active lesions). There were no grade ≥3 BRT toxicities. Grade ≥3 CRS occurred in 9 pts (8%), including 8/82 (10%) after axi-cel and 1/31 (3%) after tisa-cel. Grade ≥3 ICANS occurred in 23 pts (20%), including 22/82 (27%) after axi-cel and 1/31 (3%) after tisa-cel. Median follow up was 26.9 months. 1- and 2-year OS rates were 60% and 49%. 1- and 2-year PFS rates were 41% and 35%. Comprehensive BRT associated with superior PFS (HR 0.34, 95% CI 0.19-0.62, p<0.001) in a multivariable model with age ≥60, ECOG ≥2, advanced stage, CNS disease, pre-leukapheresis LDH, and axi-cel.

CONCLUSION

In this multi-institutional study, pts receiving BRT prior to CAR T therapy for BCL frequently had bulky disease yet experienced favorable PFS and OS. There were no serious toxicities attributable to BRT, and the rates of CRS and ICANS are comparable to those after CAR T alone. Comprehensive BRT associated with superior PFS.

TEAMRO: TEAching Mentorship in Radiation Oncology, a Multicenter Prospective Phase 2 Intervention Study on Teaching Mentorship Skills to Residents Working with Medical Students

PURPOSE/OBJECTIVE(S)

While formal curriculum on resident teaching have been associated with improved career growth and sustained positive impact on patient care, mentorship skills are rarely taught in academic medicine. We hypothesized that a formalized resident mentorship curriculum coupled with a near-peer resident-medical student mentoring program would improve resident career growth.

MATERIALS/METHODS

A multi-institutional, prospective, phase 2 intervention study, approved by each participating center's institutional review board, was conducted from 4/2022-10/2022 among interested residents in the Radiation Oncology Education Collaborative Study Group Graduate Medical Education. Intervention included: 1) a 4-week mentorship curriculum (utilizing a Six Steps approach) composed of self-guided readings, didactic lecture, and 30-minute faculty check-in, and 2) a formalized 1:1 resident-medical student mentorship program during an existing radiation oncology sub-internship with weekly meetings. Resident participants completed the Mentorship Competency Assessment (MCA), a 26-item validated survey on mentorship skills in medicine scored from 0 (most unprepared) to 7 (most prepared) before and after the intervention. The primary endpoint was average change in MCA skill from pre- to post-intervention survey, with score ranges from -7 (a decrease in 7 points) to +7 (an increase of 7 points).

RESULTS

A total of 8 residents participated and all completed pre- and post-intervention surveys. Most residents were PGY-4/5 (75%), from programs with >10 residents (68%), and did not have prior training in teaching (88%) or mentorship (88%). Residents met students on average twice weekly (range 1-3) for an average of 2 hours a week (range 1-5). After the program, most residents felt confident in being a future mentor to students (100%), their overall well-being was positively impacted (63%), and their mentorship relationships were positively impacted (50%). All 26 mentorship skills increased on MCA after intervention (average +1.3/7 per skill). Skills that showed greatest improvement were helping mentees network effectively (+2.6/7), acquire resources (+2.1/7), negotiate a path to professional independence (+2.0/7), set career goals (+1.8/7), and balance work and personal life (+1.7/7). Skills that showed least improvement were establishing a relationship based on trust (+0.4/7), identifying and accommodating different communication styles (+0.6/7), providing constructive feedback (+0.7/7), and aligning mentor-mentee expectations (+0.8/7).

CONCLUSION

The formalized mentorship program improved mentorship skills among residents, translating to increased satisfaction in residents' own mentorship relations and overall well-being. Further studies are needed to assess the sustainability of these skills, as well as impact on career growth and satisfaction.

The American Society for Radiation Oncology Workforce Taskforce Review of the United States Radiation Oncology Workforce Analysis

Over the past decade, concerns have arisen in radiation oncology regarding potential workforce supply and demand imbalance. The American Society for Radiation Oncology commissioned an independent analysis in 2022, looking at supply and demand in the United States radiation oncology workforce and projecting future trends for 2025 and 2030. The final report entitled, "Projected Supply and Demand for Radiation Oncologists in the U.S. in 2025 and 2030" is now available. The analysis included evaluating radiation oncologist supply (new graduates, exits from the specialty), potential changes in demand (growth of Medicare beneficiaries, hypofractionation, loss of indications, new indications) as well as radiation oncologist productivity (growth of work RVUs produced) and demand per beneficiary. The results demonstrated a relative balance between radiation oncology supply and demand for radiation services; the growth in radiation oncologists was balanced by the rapid growth of Medicare beneficiaries over the same time period. The primary factors driving the model were found to be growth of Medicare beneficiaries, and change in work RVU productivity with hypofractionation and loss of indication having only a moderate impact; while the most likely scenario was a balance of workforce supply and demand, scenarios did demonstrate the possibility of over and under supply. Oversupply may become a concern if radiation oncologist wRVU productivity reaches the highest region; beyond 2030, this is also possible if growth in radiation oncologist supply does not parallel Medicare beneficiary growth. Limitations of the analysis included the lack of inclusion of most technical reimbursement and its impact as well as failing to account for SBRT. A modeling tool is available to allow individuals to evaluate different scenarios. Moving forward, continued study will be needed to evaluate trends (particularly work RVU productivity and Medicare beneficiary growth) to allow for continued assessment of workforce supply and demand in radiation oncology.

Radiation Oncology residency training program integration of diversity, equity, and inclusion: An Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee (ARRO EISC) inaugural program director survey

PURPOSE

To investigate United States (US) radiation oncology (RO) program directors' (PDs) attitudes and practices regarding racial/ethnic diversity, equity, and inclusion (DEI) to better understand potential impact on underrepresented in medicine (UIM) residents in RO.

METHODS AND MATERIALS

A 28-item survey was developed using the validated Ethnic Harassment Experiences Scale and the Daily Life Experiences subscale, as well as input from DEI leaders in RO. The survey was IRB-approved and administered to RO PDs. PDs were provided with the American Association of Medical Colleges (AAMC) definition of underrepresented in medicine (UIM), that is "Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population." Descriptive statistics were used in analysis.

RESULTS

The response rate was 71% (64/90). Institutional Culture and Beliefs: 42% responded that they had a department DEI director. A minority (17%, N=11) agreed "I believe that people from UIM backgrounds have equal access to quality tertiary education in the US." The majority (97%, N=62) agreed "My program values residents from UIM backgrounds." Support and Resources: Majority (78%, N=50) agreed "My program has resources in place to assist/provide support for resident physicians from UIM backgrounds." Interview and Recruitment: Most PDs (53%) had not taken part in activities aimed at recruiting UIM residents and 17% had interviewed no UIM applicants in the past 5 years for residency. Resident experiences of Racism: 17% (N=11) agreed "UIM residents in my program have reported incidents of racism to me," and 28% (N=18) agreed "I believe that UIM residents in my program have been treated differently because of their race/ethnicity by faculty, staff, co-residents or patients.".

CONCLUSION

Most PDs reported that they did not believe that UIM residents were treated differently in their department because of their race/ethnicity, and only a minority had received reports of racial discrimination experienced by residents. These data are in contrast to resident experiences, and suggest a disconnect between DEI perceptions and resident experiences among US RO PDs that should be addressed through increased programmatic action and evaluation.

Assessment of Lymphoma and Other Hematologic Malignancies Training Needs Among Radiation Oncology Residents: a Brief Report

The role of radiation therapy (RT) varies across hematologic malignancies (HM). Radiation oncology (RO) resident comfort with specific aspects of HM patient management is unknown. The International Lymphoma RO Group (ILROG) assessed resident HM training opportunities and interest in an HM away elective. RO residents (PGY2-5) in the Association of Residents in RO (ARRO) database (n = 572) were emailed an anonymous, web-based survey in January 2019 including binary, Likert-type scale (1 = not at all, 5 = extremely, reported as median [interquartile range]), and multiple-choice questions. Of 134 resident respondents (23%), 86 (64%) were PGY4/5 residents and 36 (27%) were in larger programs (≥ 13 residents). Residents reported having specialized HM faculty (112, 84%) and a dedicated HM rotation (95, 71%). Residents reported "moderate" preparedness to advocate for RT in multidisciplinary conferences (3 [2-3]); make HM-related clinical decisions (3 [2-4]); and critique treatment planning (3 [2-4]). They reported feeling "moderately" to "quite" prepared to contour HM cases (3.5 [3-4]) and "quite" prepared to utilize the PET-CT five-point scale (4 [3-5]). Overall, residents reported feeling "moderately" prepared to treat HM patients (3 [2-3]); 24 residents (23%) felt "quite" or "extremely" prepared. Sixty-six residents (49%) were potentially interested in an HM away elective, commonly to increase comfort with treating HM patients (65%). Therefore, HM training is an important component of RO residency, yet a minority of surveyed trainees felt quite or extremely well prepared to treat HM patients. Programs should explore alternative and additional educational opportunities to increase resident comfort with treating HM patients.

MR-Guided SBRT/Hypofractionated RT for Metastatic and Primary Central and Ultracentral Lung Lesions

Introduction

The recent results from the Nordic-HILUS study indicate stereotactic body radiation therapy (SBRT) is associated with high-grade toxicity for ultracentral (UC) tumors. We hypothesized that magnetic resonance-guided SBRT (MRgSBRT) or hypofractionated radiation therapy (MRgHRT) enables the safe delivery of high-dose radiation to central and UC lung lesions.

Methods

Patients with UC or central lesions were treated with MRgSBRT/MRgHRT with real-time gating or adaptation. Central lesions were defined as per the Radiation Therapy Oncology Group and UC as per the HILUS study definitions: (1) group A or tumors less than 1 cm from the trachea and/or mainstem bronchi; or (2) group B or tumors less than 1 cm from the lobar bronchi. The Kaplan-Meier estimate and log-rank test were used to estimate survival. Associations between toxicities and other patient factors were tested using the Mann-Whitney U test and Fisher's exact test.

Results

A total of 47 patients were included with a median follow-up of 22.9 months (95% confidence interval: 16.4-29.4). Most (53%) had metastatic disease. All patients had central lesions and 55.3% (n = 26) had UC group A. The median distance from the proximal bronchial tree was 6.0 mm (range: 0.0-19.0 mm). The median biologically equivalent dose (α/β = 10) was 105 Gy (range: 75-151.2). The most common radiation schedule was 60 Gy in eight fractions (40.4%). Most (55%) had previous systemic therapy, 32% had immunotherapy and 23.4% had previous thoracic radiation therapy. There were 16 patients who underwent daily adaptation. The 1-year overall survival was 82% (median = not reached), local control 87% (median = not reached), and progression-free survival 54% (median = 15.1 mo, 95% confidence interval: 5.1-25.1). Acute toxicity included grade 1 (26%) and grade 2 (21%) with only two patients experiencing grade 3 (4.3%) in the long term. No grade 4 or 5 toxicities were seen.

Conclusions

Previous studies noted high rates of toxicity after SBRT to central and UC lung lesions, with reports of grade 5 toxicities. In our cohort, the use of MRgSBRT/MRgHRT with high biologically effective doses was well tolerated, with two grade 3 toxicities and no grade 4/5.

Adaptive hypofractionted and stereotactic body radiotherapy for lung tumors with real-time MRI guidance

The treatment of central and ultracentral lung tumors with radiotherapy remains an ongoing clinical challenge. The risk of Grade 5 toxicity with ablative radiotherapy doses to these high-risk regions is significant as shown in recent prospective studies. Magnetic resonance (MR) image-guided adaptive radiotherapy (MRgART) is a new technology and may allow the delivery of ablative radiotherapy to these high-risk regions safely. MRgART is able to achieve this by utilizing small treatment margins, real-time gating/tracking and on-table plan adaptation to maintain dose to the tumor but limit dose to critical structures. The process of MRgART is complex and has nuances and challenges for the treatment of lung tumors. We outline the critical steps needed for appropriate delivery of MRgART for lung tumors safely and effectively.

Using Holistic Residency Applicant Review and Selection in Radiation Oncology to Enhance Diversity and Inclusion, an ASTRO SCAROP-ADROP-ARRO Collaboration

Disproportionate gender, racial, and ethnic diversity remains in the radiation oncology physician workforce despite widespread awareness and longitudinal efforts to improve representation. In this collaborative review, we define the rationale and components of holistic review and how it can be best utilized to provide a comprehensive evaluation of applicants to residency programs in radiation oncology. We initially discuss the current state of diversity in the field of radiation oncology and highlight the components of the residency selection process that may serve to perpetuate existing biases. Subsequently, the ACGME and AAMC holistic review framework is reviewed in detail to demonstrate the balanced assessment of potential applicants. The implementation of holistic review in medical school and residency selection to-date are examined to underscore the potential value of holistic review in the radiation oncology residency selection process. Finally, recommendations for the practical implementation of holistic review in radiation oncology trainee selection are outlined.

A Practical Workflow for Magnetic Resonance-Guided Stereotactic Body Radiation Therapy to the Pancreas

The increased adoption of stereotactic body radiation therapy has allowed for delivery of higher doses, potentially associated with better outcomes but at the risk of higher toxicity. The intimate association of radiosensitive organs at risk (eg, stomach, duodenum, bowel) has historically limited the delivery of ablative doses to the pancreas. The advent of magnetic resonance-guided radiation therapy with improved soft-tissue contrast allows for gated delivery without an internal target volume and online adaptive replanning to maximize the therapeutic ratio. Patient selection requires additional resources, including increased patient on-table time, physician time, and physics support. Within our center's workflow, integrating an educational video at consultation as well as optimizing biofeedback mechanisms have significantly improved the experience for our patients.

Radiation Oncology resident perspectives on diversity, equity, and inclusion: an Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee (ARRO EISC) inaugural resident survey

PURPOSE

In this study, radiation oncology residents were surveyed on perceptions of diversity, equity, inclusion, and belonging in their residency training programs.

METHODS AND MATERIALS

A 23-item survey was developed by the Association of Residents in Radiation Oncology Equity and Inclusion Subcommittee resident members and faculty advisors. The survey was divided into 4 sections: institutional culture, support and resources, interview and recruitment, and experiences of bias. The survey was sent individually to residents from all Accreditation Council for Graduate Medical Education-accredited radiation oncology programs.

RESULTS

The survey was issued to 757 residents. A total of 319 residents completed the survey, for a response rate of 42%. All postgraduate years and geographic regions were represented. Significant racial, ethnic, and gender differences were present in survey response patterns. White residents (94%, 164 of 174) and male residents (96%, 186 of 194) were more likely to strongly agree/agree that they were treated with respect by their colleagues and their coworkers than other racial groups (P < .005) or gender groups (P < .008). Only 3% (5 of 174) of White residents strongly agreed/agreed that they were treated unfairly because of their race/ethnicity, while 31% (5 of 16) of Black residents and 10% (9 of 94) of Asian residents strongly agreed/agreed (P < .0001). Similarly, Hispanic residents were more likely to strongly agree/agree (24%, 5 of 21) than non-Hispanic residents (7%, 20 of 298) (P = .003). Regarding mentorship, there were no differences by gender or ethnicity. There were differences by race in residents reporting that they had a supportive mentor (P = .022), with 89% (154 of 174) of White residents who strongly agreed/agreed, 88% (14 of 16) of Black residents, and 91% of Asian residents (86 of 94).

CONCLUSIONS

This survey reveals that experiences of support, mentorship, inclusion, and bias vary significantly among radiation oncology residents based on race, ethnicity, and gender. Radiation oncology has opportunity for growth to ensure an equitable experience for all residents.

Radiation therapy prior to CAR T-cell therapy in lymphoma: impact on patient outcomes

INTRODUCTION

Anti-CD19 chimeric antigen receptor (CAR) T-cell therapy has revolutionized the treatment paradigm for patients with refractory or recurrent (R/R) diffuse large B-cell lymphomas (DLBCL). Nonetheless, most patients ultimately progress. The use of bridging or salvage radiotherapy (RT) in combination with CAR T-cell therapy has been proposed as potential strategies to improve patient outcomes, but consensus is currently lacking as to which, if either, approach is effective.

AREAS COVERED

We reviewed the immunologic and molecular mechanisms of resistance and the current retrospective data on patterns-of-failure, clinical risk factors, and treatment outcomes in patients undergoing CAR T-cell therapy, with and without bridging or salvage RT.

EXPERT OPINION

We believe that current basic and clinical evidence supports the use of comprehensive, ablative bridging irradiation (CABI), as opposed to low-dose bridging or salvage radiotherapy, as a promising strategy to improve CAR T-cell therapy outcomes in patients with R/R DLBCL. This potential benefit is likely greatest in patients with high tumor burden and/or localized disease, who are both at elevated risk of local recurrence and can often be safely and comprehensively treated with ablative radiation doses (EQD2 > 39 Gy). Hypothesis-driven clinical trials are needed prospectively assess the impact of radiation on outcomes in patients undergoing CAR T-cell therapy.

Delivery of Online Adaptive MRI-Guided Radiation Therapy for a Deaf Patient

MRI-guided radiation therapy (MRgRT) enables real-time imaging during treatment and daily online adaptive planning. It is particularly useful for areas of treatment that have been previously excluded or restricted from ablative doses due to potential damage to adjacent normal tissue. In certain cases, ablative doses to metastatic lesions may be justified and treated with MRgRT using video-assisted gated breath-hold adjustments throughout delivery. The workflow relies on patient biofeedback and auditory cues.

A 74-year-old deaf male with a history of prostate cancer status post prostatectomy was found to have an enlarged cervical lymph node, which was excised with histopathology demonstrating Merkel cell carcinoma. Approximately one year after treatment with two cycles of pembrolizumab, which was subsequently discontinued due to toxicity, surveillance imaging demonstrated an enlarging left adrenal nodule. It was initially stable for an additional seven months with pembrolizumab rechallenge but was again found enlarged on subsequent imaging. The patient underwent MRg stereotactic body radiation therapy (MRgSBRT) to a total dose of 60 Gy in five fractions to this isolated site of progression. The patient was equipped with mirrored glasses to view the tracking structure with respect to gating the boundary structure, and the traditional reliance on verbal cues for coaching was reimagined to rely on visual cues instead. Follow-up positron emission tomography/CT (PET/CT) two weeks after treatment demonstrated interval resolution of the left adrenal metastatic nodule and a return to symmetric bilateral adrenal gland metabolic activity. The necessary MRgSBRT treatment for single metastatic lesions near normal tissue structures relies on verbal cues and coaching. However, deaf patients are unable to receive this treatment according to the traditional workflow model. Unique opportunities exist for the implementation of culturally competent care for the Deaf community, relying more heavily on visual cues, in radiation oncology practice.

Patterns and Predictors of Failure in Recurrent or Refractory Large B-Cell Lymphomas following Chimeric Antigen Receptor (CAR) T-Cell Therapy

PURPOSE

Chimeric antigen receptor T-cell (CAR T) therapy is capable of eliciting durable responses in patients with relapsed/refractory (R/R) lymphomas. However, the majority of treated patients relapse. Patterns of failure following CAR T have not been previously characterized and may provide insights into the mechanisms of resistance guiding future treatment strategies.

METHODS AND MATERIALS

Retrospective analysis of R/R large B-cell lymphoma patients treated with anti-CD19 CAR T at an NCI-designated Comprehensive Cancer Center from 2015 to 2019. Pre- and post-treatment PET/CTs were analyzed to assess the progression of existing (local failures) versus new, non-overlapping lesions (de novo failures) and to identify lesions at high-risk for progression.

RESULTS

A total of 469 pretreatment lesions in 63 patients were identified. At a median follow-up of 12•6 months, 36 (57%) patients recurred. The majority (n=31, 86%) had a component of local failure with 13 (36%) patients exhibiting strictly local failures. Even at progression, 84% of recurrent patients continued to have a subset of pretreatment lesions maintain PET/CT resolution. Lesions at high-risk for local failure included those with a diameter ≥5cm (OR 2•34, 95%CI 1•55-3•55; p<0•001), an SUV_max≥10 (OR 2•08, 95%CI 1•38-3•12; p<0•001), or that were extranodal (OR 1.49, 95% CI 1.10-2.04; p=0.01). In the 69 patients eligible for survival analysis, those with any lesion ≥5cm (n=46, 67%) experienced inferior PFS (HR 2•41, 95%CI 1•15-5•04; p=0•02) and OS (HR 3•36, 95%CI 1•17-9•96; p=0•02).

CONCLUSION

The majority of patients who recur following CAR T experience a component of local progression. Furthermore, lesions with high-risk features, particularly large size, were associated with inferior treatment efficacy and patient survival. Taken together, these observations suggest that lesion-specific resistance may contribute to CAR T treatment failure. Locally-directed therapies to high-risk lesions, such as radiotherapy, may be a viable strategy to prevent CAR T failures in select patients.

No Longer a Match: Trends in Radiation Oncology National Resident Matching Program (NRMP) Data from 2010-2020 and Comparison Across Specialties

PURPOSE

To report trends in the number and types of applicants and matched trainees to radiation oncology in comparison to other specialties participating in the National Resident Matching Program (NRMP) between 2010 and 2020.

METHODS AND MATERIALS

Data from the NRMP and Electronic Residency Application System (ERAS) were obtained for 18 medical specialties between 2010 and 2020. We assessed the numbers and types of applicants and matched trainees relative to available positions in the NRMP and Supplemental Offer and Acceptance Program (SOAP).

RESULTS

In the 2020 NRMP, 122 US MD senior graduates preferentially ranked radiation oncology, a significant decrease from a median of 187 between 2010 to 2019 (interquartile range [IQR], 170-192; P < .001). Across all 18 specialties, radiation oncology experienced the greatest declines in the 2020 NRMP cycle relative to 2010 to 2019, in both the number of ERAS applicants from the United States and Canada (-31%) and the percentage of positions filled by US MD or DO senior graduates (-28%). Of 189 available positions, 81% (n = 154) filled in the NRMP prior to the SOAP, of which 65% (n = 122) were "matched" by US MD senior graduates who preferentially ranked radiation oncology as their top choice of specialty, representing a significant decrease from a median of 92% between 2010 to 2019 (IQR, 88%-94%; P = .002). The percentages of radiation oncology programs and positions unfilled in the NRMP prior to the SOAP were significantly increased in 2020 compared with 2010 to 2019 (programs: 29% vs 8% [IQR, 5%-8%; P < .001]; positions: 19% vs 4% [IQR, 2%-4%; P <.001]). Despite >99% (n = 127 of 128) of US MD or DO senior applicants preferring radiation oncology successfully matching to a radiation oncology position in the 2020 NRMP, 16 of 35 remaining unfilled positions were filled via the SOAP. Radiation oncology was the top user of the SOAP across all specialties participating in the 2020 NRMP, filling 15% of total positions versus a median of 0.9% (IQR, 0.3%-2.3%; P <.001).

CONCLUSIONS

The supply of radiation oncology residency positions now far exceeds demand by graduating US medical students. Efforts to nullify a market correction revealed by medical student behavior via continued reliance on the SOAP to fill historical levels of training positions may not be in the best of interest of trainees, individual programs, or the specialty as a whole.

Gonadal-sparing total body irradiation with the use of helical tomotherapy for nonmalignant indications

Background

The aim was to demonstrate the feasibility and technique of gonadal sparing total body irradiation (TBI) with helical tomotherapy. Total body irradiation is a common part of the conditioning regimen prior to allogeneic stem cell transplantation. Shielding or dose-reduction to the gonads is often desired to preserve fertility, particularly in young patients undergoing transplant for non-malignant indications. Helical tomotherapy (HT) has been shown to be superior to traditional TBI delivery for organ at risk (OA R) doses and dose homogeneity.

Materials and methods

We present two representative cases (one male and one female) to illustrate the feasibility of this technique, each of whom received 3Gy in a single fraction prior to allogeneic stem cell transplant for benign indications. The planning target volume (PTV) included the whole body with a subtraction of OA Rs including the lungs, heart, and brain (each contracted by 1cm) as well as the gonads (testicles expanded by 5 cm and ovaries expanded by 0.5 cm).

Results

For the male patient we achieved a homogeneity index of 1.35 with a maximum and median planned dose to the testes of 0.53 Gy and 0.35 Gy, respectively. In-vivo dosimetry demonstrated an actual received dose of 0.48 Gy. For the female patient we achieved a homogeneity index of 1.13 with a maximum and median planned dose to the ovaries of 1.66 Gy and 0.86 Gy, respectively.

Conclusion

Gonadal sparing TBI is feasible and deliverable using HT in patients with non-malignant diseases requiring TBI as part of a pre-stem cell transplant conditioning regimen.

Pretreatment CT and 18 F-FDG PET-based radiomic model predicting pathological complete response and loco-regional control following neoadjuvant chemoradiation in oesophageal cancer

INTRODUCTION

To develop a radiomic-based model to predict pathological complete response (pCR) and outcome following neoadjuvant chemoradiotherapy (NACRT) in oesophageal cancer.

METHODS

We analysed 68 patients with oesophageal cancer treated with NACRT followed by esophagectomy, who had staging 18F-fluorodeoxyglucose (¹⁸ F-FDG) positron emission tomography (PET) and computed tomography (CT) scans performed at our institution. An in-house data-chjmirocterization algorithm was used to extract 3D-radiomic features from the segmented primary disease. Prediction models were constructed and internally validated. Composite feature, F_c  = α * F_PET  + (1 - α) * F_CT , 0 ≤ α ≤ 1, was constructed for each corresponding CT and PET feature. Loco-regional control (LRC), recurrence-free survival (RFS), metastasis-free survival (MFS) and overall survival (OS) were estimated by Kaplan-Meier analysis, and compared using log-rank test.

RESULTS

Median follow-up was 59 months. pCR was achieved in 34 (50%) patients. Five-year RFS, LRC, MFS and OS were 67.1%, 88.5%, 75.6% and 57.6%, respectively. Tumour Regression Grade (TRG) 0-1 indicative of complete response or minimal residual disease was significantly associated with improved 5-year LRC [93.7% vs 71.8%; P = 0.020; HR 0.19, 95% CI 0.04-0.85]. Four sepjmirote pCR predictive models were built for CT alone, PET alone, CT+PET and composite. CT, PET and CT+PET models had AUC 0.73 ± 0.08, 0.66 ± 0.08 and 0.77 ± 0.07, respectively. The composite model resulted in an improvement of pCR predicting power with AUC 0.87 ± 0.06. Stratifying patients with a low versus high radiomic score showed clinically relevant improvement in 5-year LRC favouring low-score group (91.1% vs. 80%, 95% CI 0.09-1.77, P = 0.2).

CONCLUSION

The composite CT/PET radiomics model was highly predictive of pCR following NACRT. Validation in larger data sets is warranted to determine whether the model can predict clinical outcomes.

Malpractice Litigation in Glaucoma

PURPOSE

To analyze and report the causes and outcomes of malpractice litigation for patients with a diagnosis of glaucoma.

DESIGN

Retrospective case series.

PARTICIPANTS

Malpractice litigation cases.

METHODS

The WestLaw database was reviewed for all malpractice litigation with ophthalmologist defendants in the United States between 1930 and 2014. All litigation involving glaucoma was included in this analysis and was compared with litigation in ophthalmology as a whole.

MAIN OUTCOME MEASURES

The primary outcomes were the number of cases, jury award amounts, whether the case resolved in favor of the defendant, and the type of glaucomatous disease or procedure with the highest amount of litigation.

RESULTS

Sixty-nine glaucoma malpractice cases were included. Overall, 62.3% of cases were resolved in favor of defendants. Twenty-nine cases were resolved via jury trial, 8 of which were associated with plaintiff verdicts with a mean adjusted jury award of $994 260. Ten cases resulted in settlements with mean adjusted indemnity of $1 210 414. Commonly litigated allegations included mismanagement of glaucoma (20.3%), failure to diagnose glaucoma (17.4%), failure to diagnose or mismanagement of angle-closure glaucoma (18.5%), adverse drug effects (14.5%), and trabeculectomy complications (8.7%). Overall, the median plaintiff award for all of glaucoma litigation was $977 476; the median award across all ophthalmic subspecialties was $568 302 (P = 0.25). For jury verdicts alone, the median award in glaucoma was $977 474, compared with $604 352 for all ophthalmology (P = 0.05). For settlements alone, the median indemnity payment in glaucoma was $955 988, compared with $827 051 for all ophthalmology (P = 0.24).

CONCLUSIONS

Overall, the rate of plaintiff verdicts was similar in glaucoma and in ophthalmology as a whole; however, the magnitude of plaintiff awards was higher in glaucoma than in ophthalmology overall. Common scenarios leading to litigation included failure to diagnose or mismanagement of glaucomatous disease, as well as adverse drug effects and surgical complications. Many cases could have been avoided with careful examinations, thorough documentation in the patients' charts, and detailed conversations with patients.

MR-guided stereotactic body radiation therapy for intracardiac and pericardial metastases

•

Radiation is not typical in the standard of care for cardiac metastases.

•

MR-guided radiation uses real-time imaging and offers better soft tissue contrast.

•

Real-time MR-guidance allows for safe high dose radiation to cardiac metastases.

•

MR-guided stereotactic radiation can improve symptoms without acute toxicity.

Aims

To assess the safety and efficacy of MR-guided stereotactic body radiation therapy (MRgSBRT) for cardiac metastases.

Materials/methods

This single institution retrospective analysis evaluated our experience with MRgSBRT for cardiac metastases. Response rate was compared between pre-RT and post-RT imaging. Symptomatic changes were also tracked and documented.

Results

Between 4/2019 and 3/2020, five patients with cardiac metastases (4 intracardiac and 1 pericardial) were treated with MRgSBRT. Median age at treatment was 73 years (range 64–80) and two patients had pre-existing cardiac disease. Histologies included melanoma and breast adenocarcinoma. Median lesion diameter was 2 cm (range 1.96–5.8 cm). Three patients were symptomatic, one of whom had pulmonary hypertension and RV enlargement. Another patient had an asymptomatic arrythmia. Median PTV prescribed dose was 40 Gy (range 40–50 Gy) and delivered in five fractions on nonconsecutive days. Median PTV volume was 53.4 cc (range 8.7–116.6 cc) and median coverage was 95% (range 84.1–100%). A uniform 3 mm margin was used for real-time gating, allowing a median 7% (range 5–10%) pixel excursion tolerance. Median follow-up was 4.7 months (range 0.9–12.3). Two patients exhibited stable disease, two had a partial response and one exhibited a complete response. All symptomatic patients experienced some relief. There were no acute adverse events, however, one patient without prior cardiac disease developed atrial fibrillation 6 months after treatment. Two patients died of causes unrelated to cardiac MRgSBRT.

Conclusion

In this largest known series of cardiac metastasis MRgSBRT, real-time image guidance enables safe treatment resulting in good response with improving presenting symptoms without acute adverse events.

Harnessing COVID-Driven Technical Innovations for Improved Multi-Disciplinary Cancer Care in the Post-COVID Era: The Virtual Patient Room

Emergence of the COVID-19 crisis has catalyzed rapid paradigm shifts throughout medicine. Even after the initial wave of the virus subsides, a wholesale return to the prior status quo is not prudent. As a specialty that values the proper application of new technology, radiation oncology should strive to be at the forefront of harnessing telehealth as an important tool to further optimize patient care. We remain cognizant that telehealth cannot and should not be a comprehensive replacement for in-person patient visits because it is not a one for one replacement, dependent on the intention of the visit and patient preference. However, we envision the opportunity for the virtual patient “room” where multidisciplinary care may take place from every specialty. How we adapt is not an inevitability, but instead, an opportunity to shape the ideal image of our new normal through the choices that we make. We have made great strides toward genuine multidisciplinary patient-centered care, but the continued use of telehealth and virtual visits can bring us closer to optimally arranging the spokes of the provider team members around the central hub of the patient as we progress down the road through treatment.

Novel MR-Guided Radiotherapy Elective Rotation for Radiation Oncology Trainees

MR-guided adaptive radiation therapy (RT) is emerging as an integral treatment modality for certain applications and is poised to become an exciting opportunity for greater treatment precision and personalization. However, this is still a relatively nascent technology and only a few institutions and programs have access to this technology for clinical use and trainee education. To increase the diversity of elective offerings and improve the understanding of an MR-guided radiotherapy program, we initiated a unique MR-guided radiotherapy elective rotation for radiation oncology residents. During a representative four-week rotation, 21 simulations were completed by the resident on service. A plurality of simulations were for pancreas stereotactic body radiation therapy (SBRT; 48%) and a majority (71%) of simulations were for adaptive treatments. Additionally, 74 adaptive fractions were completed during this month, of which a significant majority (74%) were for pancreas SBRT. Of the non-adaptive fractions, the majority were for prostate SBRT and intensity-modulated radiation therapy (IMRT). Although many programs may offer training in some aspects of MR-guided radiotherapy as trainees rotate through certain disease sites, we hope this may serve as a blueprint to encourage programs with this technology to fully embrace training in essential competencies related to MR-guided radiotherapy. MR-guided radiotherapy has unique challenges that trainees need to understand to deliver treatment safely: geometric uncertainty, MRI to RT isocenter, and uncertainties with voxel size/tracking.

A review of the role of MRI in diagnosis and treatment of early stage lung cancer

Despite magnetic resonance imaging (MRI) being a mainstay in the oncologic care for many disease sites, it has not routinely been used in early lung cancer diagnosis, staging, and treatment. While MRI provides improved soft tissue contrast compared to computed tomography (CT), an advantage in multiple organs, the physical properties of the lungs and mediastinum create unique challenges for lung MRI. Although multi-detector CT remains the gold standard for lung imaging, advances in MRI technology have led to its increased clinical relevance in evaluating early stage lung cancer. Even though positron emission tomography is used more frequently in this context, functional MR imaging, including diffusion-weighted MRI and dynamic contrast-enhanced MRI, are emerging as useful modalities for both diagnosis and evaluation of treatment response for lung cancer. In parallel with these advances, the development of combined MRI and linear accelerator devices (MR-linacs), has spurred the integration of MRI into radiation treatment delivery in the form of MR-guided radiotherapy (MRgRT). Despite challenges for MRgRT in early stage lung cancer radiotherapy, early data utilizing MR-linacs shows potential for the treatment of early lung cancer. In both diagnosis and treatment, MRI is a promising modality for imaging early lung cancer.

Malpractice Litigation in Ophthalmic Trauma

Objective

To report and analyze the causes and outcomes of malpractice litigation in ophthalmic trauma.

Methods

The Westlaw^® database was reviewed for ophthalmology litigation in the United States between 1930 and 2014. All ophthalmic trauma cases were included and compared to non-traumatic ophthalmology malpractice cases.

Results

Forty-four ophthalmic trauma cases were included. Of these cases, 90.9% of ophthalmic trauma plaintiffs were male compared to 54.8% of plaintiffs in ophthalmology as a whole (P=<0.001); 34.1% of cases involved minor plaintiffs compared to 6.4% in ophthalmology as a whole (P=<0.001). Cases involving minors were more likely to be resolved in favor of the plaintiff than cases involving adult plaintiffs (53.3% vs 37.9%); however, this was not found to statistically significant (P=0.35). Overall, 54.5% of cases were resolved in favor of defendants; 40.9% of cases were resolved via jury trial with 50.0% resulting in payments to plaintiffs compared to the 29.6% rate of plaintiff verdicts in ophthalmology as a whole. Open globe injuries represented 61.4% of cases; 55.6% of these cases had intraocular foreign bodies and 37.0% developed endophthalmitis. Most cases (63.6%) alleged insufficient intervention. Of these cases, 31.8% of cases involved surgical or procedural claims, and 4.5% involved medical claims only.

Conclusion

Males and minors were overrepresented among plaintiffs in ocular trauma litigation. Most cases involved open globe injuries, often complicated by retained intraocular foreign bodies and endophthalmitis. Analysis of malpractice litigation in ophthalmic trauma calls attention to commonly litigated scenarios to improve clinical practice and to inform risk management.

Malpractice Litigation in Vitreoretinal Surgery and Medical Retina

BACKGROUND AND OBJECTIVE

To report and analyze the causes and outcomes of vitreoretinal surgery and medical retina malpractice litigation.

PATIENTS AND METHODS

The WestLaw database was reviewed for all vitreoretinal malpractice litigation in the United States between 1930 and 2014.

RESULTS

One hundred forty-two retina cases were included. Overall, 64.1% of cases were resolved in favor of defendants. Eighty-three (58.5%) cases were resolved via jury trial, 30.1% of which were associated with plaintiff verdicts with mean adjusted jury award of $5,222,894 (median, $691,974). Eight cases (5.6%) resulted in settlements with mean adjusted indemnity of $726,003 (median: $437,165). Jury awards were higher than settlement awards (P = .04). Commonly litigated scenarios included retinal detachment (46.5%) and retinopathy of prematurity (9.2%).

CONCLUSIONS

The complexity of treating vitreoretinal problems and the high potential for vision loss inherent in many diagnoses make treating retinal problems high-risk. Many cases in this series resulted in multi-million-dollar plaintiff awards. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:272-278.].

STAT RT: a prospective pilot clinical trial of Scan-Plan-QA-Treat stereotactic body radiation therapy for painful osseous metastases

BACKGROUND

Planning and treatment of bone metastases with palliative radiotherapy often requires 1-3 weeks, resulting in patient inconvenience and delayed palliation. We developed an expedited workflow that delivers palliative stereotactic body radiation therapy (SBRT) to painful bone metastases in which CT, planning, quality assurance (QA), and initial treatment are performed one day. This prospective pilot clinical trial evaluates the feasibility, safety, efficacy, and patient satisfaction of this workflow.

METHODS

Patients with 1-3 painful bone metastases were prospectively enrolled and treated with 2-5 fractions of 5-10 Gy per fraction. Bone pain, opioid use, patient satisfaction, performance status, and quality of life were evaluated prior to and at 1, 4, 8, 12, 26, and 52 weeks post treatment. Outcomes and treatment-related toxicity were analyzed.

RESULTS

Twenty-eight patients were enrolled and 37 metastases treated, receiving an average of 21.6 Gy in 3.1 fractions. Median time from CT simulation to 1st treatment was 6.6 hours. Average worst pain scores were significantly lower at all post-treatment time points with maximal response noted at 3 months. Opioid use was not significantly different from baseline at any follow up. Performance status was significantly increased only at week 12. Bone pain quality of life was significantly increased at all time points except at 52 weeks while general quality of life was significantly increased at only weeks 8 and 26. Ninety-two percent of patients reported being mostly or completely satisfied with the treatment results from week 8 until the end of follow-up. There was no grade 3 or higher toxicities.

CONCLUSIONS

Results demonstrate that treating bone metastases with palliative SBRT via a multi-fraction Scan-Plan-QA-Treat patient centric workflow is feasible and safe. Although performance status, general quality of life, and opioid use were not significantly altered, patient satisfaction was high with this same-day treatment workflow.

Malpractice Litigation in Ocular Oncology

Aims

The aim of this study was to report and analyze the causes and outcomes of ocular oncology malpractice litigation.

Methods

The WestLaw® database was reviewed for all litigation related to ophthalmology in the United States from 1930 to 2014. All ocular oncology cases were included in this analysis and compared to other ophthalmic subspecialties.

Results

Sixteen ocular oncology malpractice cases were included in this study. Overall, 56.3% of the cases were resolved in favor of the defendant. A total of 62.5% of cases were resolved via jury verdict, with 30.0% resulting in plaintiff verdicts with mean adjusted awards of USD 511,244.48, comparable to ophthalmology as a whole. Three cases (18.8%) resulted in settlements with mean adjusted indemnities of USD 828,928.14. A total of 87.5% of cases alleged insufficient intervention resulting in loss of vision and/or death. The most common clinical entities were uveal melanoma (31.3%), retinoblastoma (12.5%), and sebaceous cell carcinoma (12.5%).

Conclusions

Ocular oncology malpractice litigation was relatively rare and outcomes generally favored defendants; however, unlike other subspecialties in ophthalmology, blindness or premature death were common to all cases, highlighting both the importance of prompt diagnosis and treatment and the difficulty inherent in diagnosing ocular malignancies.

Medical Malpractice in Uveitis: A Review of Clinical Entities and Outcomes

PURPOSE

To guide risk management in uveitis.

METHODS

Retrospective review of malpractice verdicts, rulings, and settlements.

RESULTS

The WestLaw® database was reviewed for lawsuits related to uveitis in the United States from 1930-2014. Twenty-five cases met inclusion criteria, and 48% of these were infectious. Overall, 64% of outcomes favored the defendant ophthalmologist. The most common diagnoses were viral retinitis (28%), iritis (12%), syphilis (8%), and toxoplasmosis (8%). Seven suits (28%) were resolved by settlement, with mean adjusted indemnities of $724,302 (median, $409,390; range, $127,837-2,021,887). Two cases (8%) resulted in plaintiff verdict, with adjusted awards of $1,399,800 and $630,799.

CONCLUSIONS

Despite being a rare diagnosis, viral retinitis (especially acute retinal necrosis) is the most common clinical entity associated with litigation in uveitis and should be considered early. Educating patients about potential adverse events, early testing for syphilis, and maintaining a positive relationship may also minimize risk.

Simulation as a set-up for technical proficiency: can a virtual warm-up improve live fibre-optic intubation?

BACKGROUND

Fibre-optic intubation (FOI) is an advanced technical skill, which anaesthesia residents must frequently perform under pressure. In surgical subspecialties, a virtual 'warm-up' has been used to prime a practitioner's skill set immediately before performance of challenging procedures. This study examined whether a virtual warm-up improved the performance of elective live patient FOI by anaesthesia residents.

METHODS

Clinical anaesthesia yr 1 and 2 (CA1 and CA2) residents were recruited to perform elective asleep oral FOI. Residents either underwent a 5 min, guided warm-up (using a bronchoscopy simulator) immediately before live FOI on patients with predicted normal airways or performed live FOI on similar patients without the warm-up. Subjects were timed performing FOI (from scope passing teeth to viewing the carina) and were graded on a 45-point skill scale by attending anaesthetists. After a washout period, all subjects were resampled as members of the opposite cohort. Multivariate analysis was performed to control for variations in previous FOI experience of the residents.

RESULTS

Thirty-three anaesthesia residents were recruited, of whom 22 were CA1 and 11 were CA2. Virtual warm-up conferred a 37% reduction in time for CA1s (mean 35.8 (SD 3.2) s vs. 57 (SD 3.2) s, P<0.0002) and a 26% decrease for CA2s (mean 23 (SD 1.7) s vs. 31 (SD 1.7) s, P=0.0118). Global skill score increased with warm-up by 4.8 points for CA1s (mean 32.8 (SD 1.2) vs. 37.6 (SD 1.2), P=0.0079) and 5.1 points for CA2s (37.7 (SD 1.1) vs. 42.8 (SD 1.1), P=0.0125). Crossover period and sequence did not show a statistically significant association with performance.

CONCLUSIONS

Virtual warm-up significantly improved performance by residents of FOI in live patients with normal airway anatomy, as measured both by speed and by a scaled evaluation of skills.

A unique TGFBI protein in granular corneal dystrophy types 1 and 2

PURPOSE

Types 1 and 2 granular corneal dystrophies (GCD) are primarily associated with accumulation of the R555W and R124H mutant transforming growth factor β-inducible proteins (TGFBIp) in corneal stroma, respectively. However, specific components of TGFBIp responsible for granular deposits have not been delineated. This study was undertaken to identify the mutant TGFBIp components potentially responsible for GCD.

METHODS

Recombinant TGFBIp of wild-type (WT) and three mutants, R124C, R124H, and R555W, were generated in HEK293FT cells. WT and TGFBIp mutants were collected from cell lysates. Immunoblot analyses were performed with five different antibodies directed against various regions of WT TGFBIp.

RESULTS

WT and TGFBIp mutants showed differential reactivities with these antibodies. In contrast to our prior observation in purified WT and TGFBIp mutants, TGFBIp from cell lysates were less prone to polymerize. A unique 35 kD fragment was detected in cell lysates of R555W and R124H, but not in those of WT or R124C, by a commercial antibody raised against amino acids (a.a.) 199-406 of TGFBIp.

CONCLUSIONS

Monomeric and polymeric WT and TGFBIp mutants were observed in vitro. The 35 kD fragment found only in R555W and R124H, but not in WT and R124C cell lysates, is likely a degraded TGFBIp derived from the central domain of these mutants and this fragment may be contributory to the nonamyloid granular deposits observed in GCD 1 and 2.

Unique TGFBI protein in lattice corneal dystrophy

PURPOSE

Specific components of transforming growth factor-beta-induced protein (TGFBIp) responsible for amyloid deposits in lattice corneal dystrophy (LCD) have not been delineated. LCD has been associated with various TGFBIp mutations such as R124C, L518P, and L527R. Using recombinant TGFBIp, this study was undertaken to identify TGFBIp components potentially contributing to the protein deposits in LCD.

METHODS

Recombinant wild-type (WT) TGFBIp and four mutants (R124C, R124H, L518P, and L527R) were generated in HEK293FT cells. WT and mutant TGFBIp were collected from crude cell lysates or purified from culture media. Immunoblot analyses were performed with four different anti-TGFBIp antibodies raised against various regions of TGFBIp.

RESULTS

Consistent with the authors' previous findings, purified recombinant proteins are more prone to polymerize than crude cell lysates. As expected, all monomers and polymers of TGFBIp WT and mutants were detected by these antibodies. However, the authors noted WT and TGFBIp mutants showed differential reactivities with these antibodies. A 47-kDa band was detected in purified 2-tag proteins of L518P by all four antibodies. A unique 43-kDa band was detected in both 1-tag cell lysates and purified proteins of R124C by the authors' custom-made antibody (KE50) and a commercial anti-TGFBIp.

CONCLUSIONS

Based on its universal reactivity with various antibodies, the authors surmise that the 47-kDa protein is a ubiquitous TGFBIp fragment derived from the N-terminus of the L518P mutant. The fact that the 43-kDa protein fragment was present primarily in R124C and R124H but not in WT implicates its potential role in the protein deposits of LCD.

Isotonic biaxial loading of fibroblast-populated collagen gels: a versatile, low-cost system for the study of mechanobiology

We developed a simple, versatile system for applying a range of biaxial loads to cell-matrix constructs for the study of mechanobiology. The system consists of porous polyethylene bars that are polymerized into a square fibroblast-populated gel and loaded by freely hanging weights attached to sutures routed through a custom loading rig. The cost to manufacture each mold/loading rig pair was less than US dollars 250 and the expected life of the components is up to 10 years. Neonatal and adult cardiac fibroblasts contracted gels to a decreasing extent as external load was increased ( P=0.003) and achieved contraction forces of up to 1.4 mN per million cells. Strain distributions were reasonably homogeneous in the central region of the gel (25% of gel area), but clearly nonhomogeneous outside that central region. The primary advantages of this system are simplicity, low cost, biaxial loading, and the ability to test for a dose-response effect of mechanical load. The current disadvantages are the inability to apply cycling loading and the inhomogeneities introduced by the use of rigid loading bars.

Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomised clinical trial

OBJECTIVE

To assess two techniques of primary closure after excision of pilonidal sinus.

DESIGN

Prospective randomised study.

SETTING

University department of surgery, United Arab Emirates.

SUBJECTS

46 patients with chronic pilonidal sinus disease, 24 treated by rhomboid flap transposition, and 22 by deep suturing technique.

MAIN OUTCOME

Early mobility and recurrence.

RESULTS

All patients in the rhomboid flap transposition group healed their wounds primarily compared with 17 in the primary deep suturing group (77%). (P = 0.02). Five patients wounds broke down as a result of haematoma and infection (23%). The mean hospital stay for the rhomboid flap technique was 6 days compared with 9 days after deep suturing, and the mean follow up for both groups was 18 months, the rhomboid flap group returned to work a mean of nine days earlier than the deep suturing group (23 days). No recurrence has been identified yet in the rhomboid flap group, while 2 recurrences have developed in the deep suturing group (9%).

CONCLUSION

Primary closure after excision of pilonidal sinus with a transposed rhomboid flap is successful in the management of pilonidal sinus and is superior to primary closure by deep suturing.

Early patient discharge following appendicectomy: safety and feasibility

One hundred and twenty patients with non-perforated acute appendicitis were discharged within 72 h of operation; 50 left hospital within 48 h of surgery. Criteria adopted for early discharge were: stable vital signs, active bowel sounds, ambulation and ability to tolerate fluid and food without discomfort. The patient's contact address was taken and every patient was requested to report to the out-patient department on the 7th post-operative day to remove stitches and assess the wound. There were three re-admissions. Five patients, however developed wound problems, three had wound infections, one had an indurated painful wound and the last developed erythema; the latter two patients were treated on an out-patient basis. Twenty patients were not happy about early discharge. Early discharge following appendicectomy is safe and can be practiced in uncomplicated cases of acute appendicitis.

Helicobacter pylori infection in perforated peptic ulcer disease

This study examined a possible aetiological agent, namely, Helicobacter pylori, in perforated peptic ulcer disease and its relationship to persisting ulcer. Twenty-nine patients with perforated peptic ulcer underwent simple closure of the perforation at laparotomy. A 13C urea breath test carried out on the eighth day after operation was positive in 24 patients. Fourteen of 17 patients who underwent upper gastrointestinal endoscopy 6 weeks after discharge from hospital had a positive 13C urea breath test. The biopsy urease test performed on mucosal samples taken at endoscopy was positive in 12 of these 14 patients, indicating continuing active infection with H. pylori. Seven patients with positive 13C urea breath and biopsy urease tests had persisting duodenal ulceration. None of the three patients with a negative 13C urea breath test had evidence of duodenal ulceration at endoscopy. The association between a high rate of duodenal ulcer persistence and a high incidence of H. pylori infection suggests that antibiotic therapy to eradicate this microorganism should be given to all patients with perforated peptic ulcer disease.

A randomized prospective study of cefoxitin versus piperacillin in appendicectomy

A randomized prospective study of antibiotic prophylaxis using a single dose of either cefoxitin or piperacillin is presented. The trial was carried out in Al Ain Hospital in the period 1989-1992 on 250 adult patients with non-perforated appendicitis. One group (124 patients) received 2 g cefoxitin, the other group (126 patients) 2 g piperacillin. Antibiotics were administered intravenously in the operating theatre immediately before surgery. Wound infection occurred in three patients, 2.4% of the cefoxitin group and in five patients (4%) of the second group (with no significant difference). The commonest infecting organisms were Escherichia coli (5 out of 8). Mean hospital stay for patients with wound infection was 15 days (range 12-21) compared with 6 days, (range 4-8) for non-infected cases. Prophylactic cefoxitin or piperacillin were each therefore similarly effective in minimizing the rate of wound infections in patients with non-perforated appendicitis.