Racial Disparity in Esophageal Squamous Cell Carcinoma Treatment and Survival in the United States

INTRODUCTION

Esophageal squamous cell carcinoma (ESCC) has a higher incidence and prevalence than esophageal adenocarcinoma among Black individuals in the United States. Black individuals have lower ESCC survival. These racial disparities have not been thoroughly investigated. We examined the disparity in treatment and survival stratified by ESCC stage at diagnosis.

METHODS

The Surveillance, Epidemiology, and End Results database was queried to identify patients with ESCC between 2000 and 2019. The identified cohort was divided into subgroups by race. Patient and cancer characteristics, treatment received, and survival rates were compared across the racial subgroups.

RESULTS

A total of 23,768 patients with ESCC were identified. Compared with White individuals, Black individuals were younger and had more distant disease during diagnosis (distant disease: 26.7% vs 23.8%, P < 0.001). Black individuals had lower age-standardized 5-year survival for localized (survival % [95% confidence interval]: 19.3% [16-22.8] vs 27.6% [25.1-30.2]), regional (14.3% [12-16.7] vs 21.1% [19.6-22.7]), and distant (2.9% [1.9-4.1] vs 6.5% [5.5-7.5]) disease. Black individuals were less likely to receive chemotherapy (54.7% vs 57.5%, P = 0.001), radiation (58.5% vs 60.4%, P = 0.03), and surgery (11.4% vs 16.3%, P < 0.0001).

DISCUSSION

Black individuals with ESCC have a lower survival rate than White individuals. This could be related to presenting at a later stage but also disparities in which treatments they receive even among individuals with the same stage of disease. To what extent these disparities in receipt of treatment is due to structural racism, social determinants of health, implicit bias, or patient preferences deserves further study.

Social Network Diversity and the Daily Burden of Inflammatory Bowel Disease

INTRODUCTION

To examine the association between social network, daily inflammatory bowel disease (IBD) burden, and related cognitive factors such as loneliness and psychological well-being.

METHODS

Using survey data, we compared the relationship between social network diversity and daily IBD burden with multivariable linear regression.

RESULTS

Patients with IBD with higher social network diversity reported a lower daily IBD burden. This association was more common among those who reported a higher degree of loneliness than those with a low degree of loneliness.

DISCUSSION

We should consider diverse social connections as an indicator of risk for higher IBD burden, especially among lonely patients.

Developing a Standard Set of Patient-Centred Outcomes for Inflammatory Bowel Disease-an International, Cross-disciplinary Consensus

BACKGROUND AND AIMS

Success in delivering value-based healthcare involves measuring outcomes that matter most to patients. Our aim was to develop a minimum Standard Set of patient-centred outcome measures for inflammatory bowel disease [IBD], for use in different healthcare settings.

METHODS

An international working group [n = 25] representing patients, patient associations, gastroenterologists, surgeons, specialist nurses, IBD registries and patient-reported outcome measure [PROM] methodologists participated in a series of teleconferences incorporating a modified Delphi process. Systematic review of existing literature, registry data, patient focus groups and open review periods were used to reach consensus on a minimum set of standard outcome measures and risk adjustment variables. Similar methodology has been used in 21 other disease areas [www.ichom.org].

RESULTS

A minimum Standard Set of outcomes was developed for patients [aged ≥16] with IBD. Outcome domains included survival and disease control [survival, disease activity/remission, colorectal cancer, anaemia], disutility of care [treatment-related complications], healthcare utilization [IBD-related admissions, emergency room visits] and patient-reported outcomes [including quality of life, nutritional status and impact of fistulae] measured at baseline and at 6 or 12 month intervals. A single PROM [IBD-Control questionnaire] was recommended in the Standard Set and minimum risk adjustment data collected at baseline and annually were included: demographics, basic clinical information and treatment factors.

CONCLUSIONS

A Standard Set of outcome measures for IBD has been developed based on evidence, patient input and specialist consensus. It provides an international template for meaningful, comparable and easy-to-interpret measures as a step towards achieving value-based healthcare in IBD.

Systematic review with network meta-analysis: the efficacy of anti-TNF agents for the treatment of Crohn's disease

BACKGROUND

Anti-tumour necrosis factor-alpha agents (anti-TNF) are effective therapies for the treatment of Crohn's disease (CD), but their comparative efficacy is unknown.

AIM

To perform a network meta-analysis comparing the efficacy of anti-TNF therapies in CD.

METHODS

After screening 506 studies, reviewers extracted information on 10 studies. Traditional meta-analysis (TMA) was used to compare each anti-TNF agent to placebo. Bayesian network meta-analysis (NMA) was performed to compare the effects of anti-TNF agents to placebo. In addition, sample sizes for comparative efficacy trials were calculated.

RESULTS

Compared to placebo, TMA revealed that anti-TNF agents result in a higher likelihood of induction of remission and response (RR: 1.66, 95% CI: 1.17-2.36 and RR: 1.43, 95% CI: 1.17-1.73, respectively) as well as maintenance of remission and response (RR: 1.78, 95% CI: 1.51-2.09 and RR: 1.68, 95% CI: 1.46-1.93, respectively). NMA found nonsignificant trends between infliximab and adalimumab or certolizumab pegol. Among subcutaneous therapies, NMA demonstrated superiority of adalimumab to certolizumab pegol for induction of remission (RR: 2.93, 95% CrI: 1.21-7.75). Sample size calculations suggest that adequately powered head-to-head comparative efficacy trials would require greater than 3000 patients.

CONCLUSIONS

All anti-TNF agents are effective for induction and maintenance of response and remission in the treatment of CD. Although adalimumab is superior to certolizumab pegol for induction of remission, there is no evidence of clinical superiority among anti-TNF agents. Head-to-head trials among the anti-TNF agents are impractical in terms of size and cost.

Extra-intestinal malignancies in inflammatory bowel disease: results of the 3rd ECCO Pathogenesis Scientific Workshop (III)

The incidence of lymphoproliferative disorders (LD) is increasing in developed countries. Patients with inflammatory bowel disease (IBD) exposed to thiopurines are at additional risk of three specific forms of LD: Epstein-Barr-Virus-related post-transplant like LD, hepato-splenic T-cell lymphoma and post-mononucleosis lymphoproliferation. The risk of the two latter forms of LD can be reduced when considering specific immunosuppressive strategies in young males. It is still unclear whether the risk of uterine cervix abnormalities is increased in IBD women, irrespective of the use of immunosuppressants. Given the excess risk demonstrated in various other contexts of immunosuppression, it is currently recommended that all women with IBD, particularly those receiving immunosuppressants, strictly adhere to a screening program of cervical surveillance and undergo vaccination against HPV, when appropriate. Patients with IBD receiving immunosuppressants are at increased risk of skin cancers. The risk of non-melanoma skin cancer is notably increased in patients receiving thiopurines. Recent data suggest that the risk of melanoma is mildly increased in patients exposed to anti-TNF therapy. All IBD patients should adhere to a program of sun protection and dermatological surveillance, whose details should take into account the other non-IBD-related risk factors.

EMerging BiomARKers in Inflammatory Bowel Disease (EMBARK) study identifies fecal calprotectin, serum MMP9, and serum IL-22 as a novel combination of biomarkers for Crohn's disease activity: role of cross-sectional imaging

OBJECTIVES

In Crohn's disease (CD), clinical symptoms correspond poorly to inflammatory disease activity. Biomarkers reflective of mucosal and bowel wall inflammation would be useful to monitor disease activity. The EMBARK study evaluated disease activity in patients with ulcerative colitis (UC) and CD, and used endoscopy with or without cross-sectional imaging for biomarker discovery.

METHODS

UC (n=107) and CD (n=157) patients were characterized and underwent ileocolonoscopy (ICO). A subset of CD patients (n=66) also underwent computed tomography enterography (CTE). ICO and CTE were scored by a gastroenterologist and radiologist who incorporated findings of inflammation into a single score (ICO-CTE) for patients that underwent both procedures. Serum and fecal biomarkers were evaluated for association with the Mayo Clinic endoscopy score in UC patients and with ICO alone or ICO-CTE in CD patients. Individual biomarkers with a moderate degree of correlation (P≤0.3) were evaluated using multivariate analysis with model selection using a stepwise procedure.

RESULTS

In UC, ordinal logistic regression using Mayo Clinic endoscopy subscore selected the combination of fecal calprotectin and serum matrix metalloproteinase 9 (MMP9; pseudo R(2)=0.353). In CD, we found that use of the ICO-CTE increased specificity of known biomarkers. Using ICO-CTE as the dependent variable for biomarker discovery, the selected biomarkers were the combination of fecal calprotectin, serum MMP9, and serum IL-22 (r=0.699).

CONCLUSIONS

Incorporation of both ICO and CTE into a single measure increased biomarker performance in CD. Combinations of fecal calprotectin and serum MMP9 for UC, and combinations of fecal calprotectin, serum MMP9, and serum interleukin-22 in CD, demonstrated the strongest association with imaging/endoscopy-defined inflammation.

The human gut microbiome: current knowledge, challenges, and future directions

The Human Genome Project was completed a decade ago, leaving a legacy of process, tools, and infrastructure now being turned to the study of the microbes that reside in and on the human body as determinants of health and disease, and has been branded "The Human Microbiome Project." Of the various niches under investigation, the human gut houses the most complex and abundant microbial community and is an arena for important host-microbial interactions that have both local and systemic impact. Initial studies of the human microbiome have been largely descriptive, a testing ground for innovative molecular techniques and new hypotheses. Methods for studying the microbiome have quickly evolved from low-resolution surveys of microbial community structure to high-definition description of composition, function, and ecology. Next-generation sequencing technologies combined with advanced bioinformatics place us at the doorstep of revolutionary insight into the composition, capability, and activity of the human intestinal microbiome. Renewed efforts to cultivate previously "uncultivable" microbes will be important to the overall understanding of gut ecology. There remain numerous methodological challenges to the effective study and understanding of the gut microbiome, largely relating to study design, sample collection, and the number of predictor variables. Strategic collaboration of clinicians, microbiologists, molecular biologists, computational scientists, and bioinformaticians is the ideal paradigm for success in this field. Meaningful interpretation of the gut microbiome requires that host genetic and environmental influences be controlled or accounted for. Understanding the gut microbiome in healthy humans is a foundation for discovering its influence in various important gastrointestinal and nutritional diseases (eg, inflammatory bowel disease, diabetes, and obesity), and for rational translation to human health gains.

Evaluation of surface and superficial dose for head and neck treatments using conventional or intensity-modulated techniques

With increased use of intensity-modulated radiation therapy (IMRT) for head and neck treatment questions have arisen as to selection of an optimum treatment approach when either superficial sparing or treatment is desired. Other work has pointed out the increased superficial dose resulting from obliquity effects when multiple tangential beams are applied to head and neck treatment, as is the general case in IMRT planning. Helical tomotherapy might be expected to result in even further enhanced superficial dose compared with conventional bilateral field treatment. We have designed a typical right oropharynx target volume in an anthropomorphic head and neck phantom. Three different treatment techniques have been used to optimally treat this target, including bilateral static fields, eight-field IMRT and helical tomotherapy. The phantom was immobilized in a standard treatment position and treated on a Varian 2300cd linear accelerator and on a Hi-Art Helical Tomotherapy unit. 1 mm3 lithium-fluoride thermoluminescent dosimeters (TLDs) were placed on the surface of the phantom at a number of axial test positions. Film strips (Kodak EDR2) were either wrapped around the surface or sandwiched within the phantom. Measured doses at the surface and as a function of depth are compared with the planning system predictions for each treatment technique. The maximum surface doses on the proximal treatment side, averaged from TLDs and films, were measured to be 69-82% of the target dose with the bilateral fields yielding the lowest surface doses (69%), tomotherapy about 2% more than that (71%) and IMRT 13% more (82%). Anterior to the target volume, doses are always low for bilateral treatment. In this case the minimum anterior surface dose (chin area) was 6% of the prescription dose from that technique as compared with 26% and 35% from the IMRT and tomotherapy methods, respectively. The Eclipse and Tomotherapy planning systems both modelled deep and superficial doses well. Surface doses were better modelled by Eclipse at the test points, while the tomotherapy plans consistently overestimated the measured doses by 10% or more. Depth dose measurements, extracted from embedded films, indicated the depth of dose build-up to >99% to be the shallowest for IMRT (2-5 mm) followed by tomotherapy (5-8 mm) and bilateral fields (10-15 mm). The amount of surface dose is clearly technique dependent and should be taken into account in the planning stage.

Dose uncertainty due to aperture effects in dynamic fields

Dosimetry of intensity modulated radiation therapy requires accurate modeling of the beamlets that comprise each treatment segment. Planning systems such as Varian Eclipse and Philips Pinnacle recommend measuring dose distributions and output factors for fields as small as possible, generally down to at least 2 x 2 cm2. Conventionally, we perform these measurements for regular fields, defined by the secondary collimators. In practice, it is the multileaf collimation system (MLC) that defines the intensity map and provides dynamic dose modulation in either a moving window or segmented step-and-shoot mode. For this review we have only considered the latter delivery mode. Using this method, we have studied aperture motion effects on the dynamic collimator scatter (S(c)), total scatter (S(c,p)), and phantom scatter (S(p)) factors for various combinations of collimator settings (4 x 4-14 x 40 cm2) and dynamically stepped leaf gaps (0.1 to 1.0 cm) in comparison with those for static field factors. For two different Varian linear accelerators, we found similar results in a systematic dependence of collimator scatter on gap width and collimator setting. As the gap increases from 0.1 to 1.0 cm the dynamic collimator scatter factors converge from a maximum difference of about 30% toward the static field values. At the same time, there is no measurable difference between dynamic field phantom scatter factors and those conventionally obtained for static fields. Second, we evaluated the two planning systems as to how well they account for collimator scatter by attempting to mimic the dynamic apertures used above by planning and measuring dose distributions to several small, cylindrical targets for a similar range of fixed collimator settings. We found that the ratio of measured-to-planned doses as a function of target size were similar to the measured, dynamic S(c) data for the Varian Eclipse planning system, indicating underestimation of dose for targets smaller than 1 cm diameter, but were close to unity for the Philips Pinnacle system, suggestive of the underlying differences in the dose calculation algorithms. We discuss the measurements and results and potential impact on the dosimetry of small clinical targets.

Evaluation of bladder dose in intensity-modulated radiation therapy of the prostate

Day-to-day variation in bladder and rectal filling affects prostate location and positioning accuracy. Systems using ultrasonic localization or gold seed placement are most often used to help correct for these changes. At some institutions, patients are instructed to empty their rectum and fill their bladders prior to treatment in an attempt to standardize the prostate location, displace small bowel out of the radiation field, and move some of the bladder wall away from the high-dose area. Although instructed to come to treatment with a full bladder, it is presumed that there is variability in bladder filling each day of treatment, depending on the amount of fluids consumed and time to treatment. We have reviewed daily bladder volumes on a subset of 5 prostate patients, all of them prescribed to receive 7560 cGy in 42 fractions, and have evaluated the dosimetric consequences of bladder volume changes from full to two-third or one-third filling. All of these patients' positions were verified daily with ultrasonic localization. Those measurements have been used to help analyze the actual treated bladder volumes for comparison with the treatment plan. We find that, in general, maximum filling only occurred on the initial simulation/image acquisition day and was typically smaller on all the following treatment days. Based on our dose-volume model, we estimate that average bladder daily doses were 8-50% higher than predicted by the initial intensity-modulation radiation therapy (IMRT) plan.

In vivodiode dosimetry for routine quality assurance in IMRT

Due to the complexity of IMRT dosimetry, dose delivery evaluation is generally done using a treatment plan in which the optimized fluence distribution has been transferred to a test phantom for accessibility and simplicity of measurement. The actual patient doses may be reconstructed in vivo through the use of electronic portal imaging devices or films, but the assessment of absolute dose from these measurements is time-consuming and complicated. In our clinic we have instituted the use of routine diode dosimetry for IMRT patients following the same procedure used for standard radiation therapy patients in which each new treatment field is checked at the start of treatment. For standard cases the dose at dmax is calculated as part of the monitor unit calculation. For the IMRT cases, the dose contribution to the dmax depth for each field is taken from the treatment plan. We found that about 90% of the diode measurements agreed to within +/- 10% of the planned doses (45/51 fields) and 63% (32/51 fields) achieved +/- 5% agreement. By using this direct in vivo method to verify the clinical doses delivered, we have been able to make a uniform startup procedure for all patients while simplifying our IMRT QA process.

Field equivalence for clinical electron beams

The concept of field equivalence for electron beams is examined using a pencil beam theory applied to circular fields. It is shown that a circular field can be found for a field of any size, shape and energy for which the depth dose distribution is approximately equivalent. The usefulness of the concept in clinical dosimetry is discussed.

The role of radiosurgery for multiple brain metastases

Object

The authors evaluated the role of stereotactic radiosurgery (SRS) in patients with multiple brain metastases by analyzing prognostic factors that predict survival.

Methods

Between March 1991 and January 1999, 83 patients with multiple brain metastases underwent SRS in which they used a 6 mV linear accelerator. The median radiation dose of 15 Gy (range 6–50 Gy) was delivered to the 40 to 90% (median 87%) isodose line encompassing the target. Actuarial overall survival was calculated from the date of SRS by using the Kaplan–Meier method. Univariate comparisons of survival between different groups were performed using a log-rank test. All 83 patients were included in the calculation of overall survival. Actuarial overall survival was 22% at 1 year and 13% at 2 years, and a median survival of 5.4 months (range, 0.3–28.8 months) was demonstrated. Variables that predicted survival were Karnofsky Performance Scale (KPS) score, extracranial disease status, and the number of intracranial metastases. Median survival in patients with a KPS score greater than as compared with less than 70 was 9.1 and 2.7 months, respectively (p = 0.002). Median survival when comparing absence and presence of extracranial disease was 9.9 and 4.1 months, respectively (p = 0.02). Median survival in patients harboring two, three, or four or more lesions was 6.6 months, 5.4 months, and 2.7 months, respectively (p = 0.02). In patients with a KPS score greater than or equal to 70 and with three or fewer lesions, median survival was 7 months or longer. In patients with four or more lesions median survival was 7.4 months for those with no extracranial disease and 2.4 months for those with extracranial disease. Other variables tested (sex, histological tumor type, previous resection, location of metastases, treatment modality, and tumor status) did not influence outcome.

Conclusions

The absence of extracranial disease, a KPS score greater than or equal to 70, and fewer number of metastases were shown to be significant predictors of longer survival. Stereotactic radiosurgery appears to be a reasonable therapeutic option in patients with up to three lesions when their KPS score is greater than or equal to 70, regardless of extracranial disease status. In those with four or more metastases, however, SRS should be limited to those with no extracranial disease.

Single dose versus fractionated stereotactic radiotherapy for recurrent high-grade gliomas

PURPOSE

To evaluate the efficacy of stereotactic radiotherapy (SRT) in patients with recurrent high-grade gliomas by comparing two different treatment regimens, single dose or fractionated radiotherapy.

METHODS AND MATERIALS

Between April 1991 and January 1998, 71 patients with recurrent high-grade gliomas were treated with SRT. Forty-six patients (65%) were treated with single dose radiosurgery (SRS) and 25 patients (35 %) with fractionated stereotactic radiotherapy (FSRT). For the SRS group, the median radiosurgical dose of 17 Gy was delivered to the median of 50% isodose surface (IDS) encompassing the target. For the FSRT group, the median dose of 37.5 Gy in 15 fractions was delivered to the median of 85% IDS.

RESULTS

Actuarial median survival time was 11 months for the SRS group and 12 months for the FSRT group (p = 0.3, log-rank test). Variables predicting longer survival were younger age (p = 0.006), lower grade (p = 0.0006), higher Karnofsky Performance Scale (KPS) (p = 0.0005), and smaller tumor volume (p = 0.02). Patients in the SRS group had more favorable prognostic factors, with median age of 48 years, KPS of 70, and tumor volume of 10 ml versus median age of 53 years, KPS of 60, and tumor volume of 25 ml in the FSRT group. Late complications developed in 14 patients in the SRS group and 2 patients in the FSRT group (p<0.05).

CONCLUSION

Given that FSRT patients had comparable survival to SRS patients, despite having poorer pretreatment prognostic factors and a lower risk of late complications, FSRT may be a better option for patients with larger tumors or tumors in eloquent structures. Since this is a nonrandomized study, further investigation is needed to confirm this and to determine an optimal dose/fractionation scheme.

Kinetics of mammary clonogenic cells and rat mammary cancer induction by X-rays or fission neutrons

Following the hormonal treatment of rats with high prolactin levels and glucocorticoid deficiency (Prl+/Glc-) for 48 days (Day +48), total recoverable mammary DNA was increased by more than sevenfold, tritiated thymidine uptake by nearly fourfold, and total mammary clonogens by about fivefold. Irradiation with 4, 40, and 80 cGy X-rays on Day +48 increased total mammary carcinomas per rat-day-at-risk linearly with dose, and 40 and 80 cGy significantly decreased first carcinoma latency. A dose of 40 cGy X-rays before hormone treatment (Day -1) yielded tumor latencies and frequencies insignificantly different from unirradiated controls but significantly different from those when the dose was given on Day +48. Total carcinomas per rat-day-at-risk were fitted better by a function of dose to the power 0.4 than by a linear function after exposure to 1, 10. and 20 cGy fission neutrons, and 10 and 20 cGy significantly shortened the time to appearance of the first cancer. In contrast to results with X-rays, 10 cGy neutrons on Day -1 yielded tumor frequencies and latencies insignificantly different from 10 cGy neutrons on Day +48. The carcinogenic action of X-rays, but not of neutrons, was thus influenced by total clonogen numbers and/or proliferation rates.

Calculation of depth dose and dose per monitor unit for irregularly shaped electron fields: an addendum

Electron beam output (dose/MU) is generally specified at the depth of maximum dose (zmax). The location of this point depends on beam energy, field size and field shape. Useful relationships have been developed to estimate zmax as a function of field size and beam energy. The formalism uses a pencil beam theory applied to circular fields.

Patient selection criteria for the treatment of brain metastases with stereotactic radiosurgery

In this study we evaluate prognostic factors that predict local-regional control and survival following stereotactic radiosurgery (SRS) in patients with brain metastasis and establish guidelines for patient selection. Our evaluation is based on 73 patients with brain metastasis treated with SRS at the University of Minnesota between March 1991 and November 1995. The ability of stereotactic radiosurgery to improve local control in patients with brain metastases is confirmed in our study in which only 6 of 62 patients failed locally after SRS, with an actuarial local progression-free survival of 80% at 2 years. Variables that predicted worse prognosis were larger tumor size (p = 0.05) for local progression-free survival and multiplicity of metastasis (p = 0.03) and infratentorial location of metastases (p = 0.006) for regional progression-free survival. Absence of extracranial disease, KPS > or = 70, and single intracranial metastasis were significant predictors of longer survival. Patients who fulfill all three criteria will survive longer after SRS (MS = 17.7 months) and will most likely benefit from the increase local control in the brain achieved by SRS. Survival in patients who do not meet any of these criteria is very poor (MS = 1.5 months), and these patients are less likely to benefit from this treatment. Careful selection of patients for SRS is warranted.

Calculation of depth dose and dose per monitor unit for irregularly shaped electron fields

A new dosimetric quantity, the lateral build-up ratio (LBR), has been introduced to calculate depth dose distribution for any shaped field. Factors to account for change in incident fluence with collimation are applied separately. The LBR data for a small circular field are used to extract radial spread of the pencil beam, sigma(r), as a function of depth and energy. By using the relationship between LBR, sigma(r), energy and depth, a formalism is developed to calculate dose per monitor unit for any shaped field. Criteria for lateral scatter equilibrium are also developed which are useful in clinical dosimetry.

Blocked field effects on collimator scatter factors

In routine dosimetry we assume separability of the collimator (Sc) and phantom (Sp) scatter components that together comprise the total scatter factor (Sc,p). In practice, the addition of blocking also affects the photon fluence attributable to the treatment head and flattening filter in a complicated way. The reduced aperture blocks out some of the head scatter contribution, while the block and tray add back secondary scatter. In the following we present techniques for directly measuring the aperture effect on Sc in air or in a full-scatter phantom. The change in Sc is found to be a scaleable quantity that can be modelled as a simple linear fit to the ratio of projected open-to-blocked equivalent square fields. Measurements have been made for 6, 18 and 24 MV photon beams on one Varian 2500 and two Varian 2100c accelerators. Results indicate a progressive loss of collimator scatter contribution with increased field blocking that is amplified with increasing energy. Block and tray scatter only contribute significantly to Sc for large fields and treatment distances of 80 cm or less. Application of these corrections in monitor unit calculations is presented.

Cost-benefit analysis of 3D conformal radiation therapy

BACKGROUND

The potential of 3D conformal radiation therapy to improve the efficacy of radiotherapy is one of the most important technical advances in recent years. The potential benefit of improved local control from dose escalation must be weighed against the potential cost of increased complications to normal tissue.

METHOD AND RESULTS

We evaluated the cost-benefit of 3D conformal radiation therapy in terms of the benefit to tumor cure weighed against the cost of complications to normal tissue. Assessment of current data shows that problems remain in adequately defining variables that contribute to both the tumor cure probability (benefit) and normal tissue complication probability (cost). For tumor cure probability, identifying the dose escalation needed for cure for the most tumor sites as well as precisely defining tumor volume remain problematic. For normal tissue complication probability, inadequate clinical data on toxicity to normal tissue for different tumor sites continue to make it difficult to use methods that estimate complications, such as dose-volume histograms as proposed by Lyman, to the clinical setting.

CONCLUSION

3D conformal radiation therapy is a promising new technology that may substantially improve the efficacy of radiation therapy. More clinical research, however, is needed to recognize the costs and benefits of this new technology: 1. Tumor control probability: More information is needed on the accurate definition of the target volume as well as on the amount of radiation necessary to cure different tumor sites. 2. Normal tissue complication probability: Methods for determining toxicity to normal tissue are needed. Current calculations based on various models are insufficient.

DP-2, a heterodimeric partner of E2F: identification and characterization of DP-2 proteins expressed in vivo

E2F is a heterodimeric transcription factor that regulates the expression of genes at the G1/S boundary and is composed of two related but distinct families of proteins, E2F and DP. E2F/DP heterodimers form complexes with the retinoblastoma (Rb) protein, the Rb-related proteins p107 and p130, and cyclins/cdks in a cell cycle-dependent fashion in vivo. E2F is encoded by at least five closely related genes, E2F-1 through -5. Here we report studies of DP-2, the second member of the DP family of genes. Our results indicate that (i) DP-2 encodes at least five distinct mRNAs, (ii) a site of alternative splicing occurs within the 5' untranslated region of DP-2 mRNA, (iii) at least three DP-2-related proteins (of 55, 48, and 43 kDa) are expressed in vivo, (iv) each of these proteins is phosphorylated, and (v) one DP-2 protein (43 kDa) carries a truncated amino terminus. Our data also strongly suggest that the 55-kDa DP-2-related protein is a novel DP-2 isoform that results from alternative splicing. Thus, we conclude that DP-2 encodes a set of structurally, and perhaps functionally, distinct proteins in vivo.

Deconvolution of detector size effect for small field measurement

Parametrization of the small fields employed in stereotactic applications is a painstaking process involving extensive film dosimetry to achieve acceptable beam edge definition. Use of cylindrical or spherical detectors for profile measurements would simplify data acquisition but add a volume averaging artifact to beam edge definition. We demonstrate a simple approach to unfolding the chamber size artifact from measured small beam profiles using typical cylindrical chambers. In comparison with film measurements we have found good agreement when the detector response function is deconvoluted from the measured profiles, although the amount of correction needed is fairly minimal for the detectors studied.

Three-dimensional conformal pancreas treatment: comparison of four- to six-field techniques

PURPOSE

We compare practical conformal treatment approaches to pancreatic cancer using 6 and 18 MV photons and contrast those approaches against standard techniques.

METHODS AND MATERIALS

A four-field conformal technique for treating pancreas cancer has been developed using nonopposed 18 MV photons. This approach has been extended to 6 MV photon application by the addition of one to two fields. These techniques have been optimized to increase sparing of normal liver and bowel, compared with opposed-field methods, to improve patient tolerance of high doses. In this study we compare these techniques in a simulated tumor model in a cylindrical phantom. Dose-volume analysis is used to quantify differences between the conformal, nonopposed techniques with conformal, opposed field methods. This model is also used to evaluate the effect of 1-2 cm setup errors on dose-volume coverage.

RESULTS

Dose-volume analysis demonstrates that five-to-six field conformal treatments using 6 MV photons provides similar or better dose coverage and normal tissue sparing characteristics as an optimized 18 MV, four-field approach when 1-2 cm margins are included for setup uncertainty. All approaches using nonopposed beam geometry provide significant reduction in the volume of tissue encompassed by the 30-50% isodose surfaces, as compared with four-field box techniques.

CONCLUSIONS

Three-dimensional (3D) conformal treatments can be designed that significantly improve dose-volume characteristics over conventional treatment designs without costing unacceptable amounts of machine time. Further, deep intraabdominal sites can be adequately accessed and treated on intermediate energy machines with a relatively moderate increase in machine time.

Sp-1 binds promoter elements regulated by the RB protein and Sp-1-mediated transcription is stimulated by RB coexpression

The retinoblastoma (RB) protein is implicated in transcriptional regulation of at least five cellular genes, including c-fos, c-myc, and transforming growth factor beta 1. Cotransfection of RB and truncated promoter constructs has defined a discrete element (retinoblastoma control element; RCE) within the promoters of each of these genes as being necessary for RB-mediated transcription control. Previously, we have shown that RCEs form protein-DNA complexes in vitro with three heretofore unidentified nuclear proteins and mutation of their DNA-binding site within the c-fos RCE results in an abrogation of RCE-dependent transcription in vivo. Here, we demonstrate that one of the nuclear proteins that binds the c-fos, c-myc, and transforming growth factor beta 1 RCEs in vitro is Sp-1 and that Sp-1 stimulates RCE-dependent transcription in vivo. Moreover, we show that Sp-1-mediated transcription is stimulated by the transient coexpression of RB protein. We conclude from these observations that RB may regulate transcription in part by virtue of its ability to functionally interact with Sp-1.

Basic radiobiological investigations of fast neutrons

The radiobiological properties of a cyclotron-produced 43-MeV (p----Be) fast-neutron beam relative to gamma rays have been investigated using Chinese hamster V79 cells in culture. As expected, the relative biological effectiveness (RBE) of this neutron beam for cell killing was shown to increase as dose decreased, and the effectiveness per unit dose was slightly less compared to a 25-MeV (d----Be) neutron beam. By tracing single cells that formed microcolonies after irradiation, we found cell proliferation kinetics to be retarded to a greater extent by fast neutrons than by gamma irradiation. Following either neutron or gamma irradiation, a fraction of the irradiated cells failed to divide in the first postirradiation division and another fraction could produce as many as four generations of progeny before proliferation stopped. The properties of these cells presumed to be destined for death suggest that more than one mechanism and/or multistep process underlies the radiation-induced proliferative death. The fast-neutron beam was also found to be more effective quantitatively than gamma rays in producing DNA double-strand breaks (DSBs, measured by nondenaturing filter elution), and G1-phase chromosome fragments (measured by the premature chromosome condensation technique). However, the reverse was observed for DNA single-strand breaks (SSBs, measured by alkaline filter elution or hydroxylapatite uncoiling). Interestingly, both fast neutrons and gamma rays produced a large component of SSBs and DSBs with a fast-rejoining time constant of about 2-5 min, which appears to be independent of dose. The latter results could not resolve the possibility of lengthening the repair-time constant by increasing radiation dose within the range that is reflected by the shoulder of the survival curve, and consequently did not support the idea of repair saturation as a mechanism for the presence of the shoulder. The RBE for the hypoxanthine phosphoribosyl transferase mutation frequency per survivor at the 10% survival level was estimated to be 2.5, a value that is comparable to the RBE (2.1) for cell killing at the same survival level. Although most of the above-mentioned findings are compatible qualitatively with the relatively high-LET (linear energy transfer) nature associated with the fast-neutron beam, the significance of the action attributable to the mixture of LET could not be delineated in these experiments. Further, the biological significance of DSBs and chromosome aberration and the molecular mechanisms responsible for the repair and expression of these damaging processes remain to be elucidated.

Influence of detector size in photon beam profile measurements

Correction is necessary to account for the detector size in clinical dosimetry of photon and electron beams. This correction is due to the absorbed dose gradient present in a finite-size detector. Further corrections are necessary when the detector and phantom materials are not the same. These corrections are due to the perturbation in the charged-particle fluence. Generally these corrections are applied to measurements along the central axis of the beam. Cross beam profile measurements, however, are not usually corrected for detector size. The ionization profile is also usually assumed to be equivalent to the absorbed dose profile. We have corrected the ionization chamber size effect by two approaches: extrapolation of measurements to zero detector size and deconvolution of measurements using a simple model for the detector response function. We have measured absorbed dose profiles to water using a small water-equivalent plastic scintillation detector. Film profile measurements were also studied. The ionization profile corrected for detector size and absorbed dose profile were not equal, probably due to loss of charged-particle equilibrium in the beam edges. For ionization chamber measurements, knowledge of the charged-particle spectrum is needed to convert ionization to absorbed dose to water. This is not necessary for relative absorbed dose measurements under charged-particle equilibrium. Film has been shown to be a straightforward and reliable method for cross beam profile measurements.

The dose distribution surrounding 192Ir and 137Cs seed sources

Dose distributions in water have been measured using LiF thermoluminescent dosimeters for 192Ir seed sources with stainless steel and with platinum encapsulation to determine the effect of differing encapsulation. The dose distribution has also been measured for a 137Cs seed source. In addition, dose distributions surrounding these sources have been calculated using the EGS4 Monte Carlo code and have been compared to the measured data. The two methods are in good agreement for all three sources. Tables are given which describe the dose distribution surrounding each source as a function of distance and angle. In addition, specific dose constants have been determined from results of Monte Carlo simulation. This work has confirmed the utility of the EGS4 Monte Carlo code in modelling 192Ir and 137Cs seed sources to obtain brachytherapy dose distributions.

Phosphorus metabolites and the distribution of cell cycle phase of RIF-1 tumors in response to 14 Gy irradiation

Simultaneous measurements of DNA cell phase cycle distributions and in vivo 31P NMR spectroscopy were performed on 40 RIF-1 murine tumors irradiated with 14 Gy of X-radiation. Diploid and tetraploid tumor populations were observed. The cells blocked in G2/M phase were measured as a function of the ratios of tetraploid cell number in G2/M phase versus total cell population measured. The G2/M population reached a maximum at 32 h post irradiation, dropping to control values by 72 h, while the ratio of inorganic phosphate to beta-nucleotide triphosphate dropped significantly at 32 h and remained significantly lower than control up to 72 h post irradiation. Measurements of PME, PDE, PCr, and pH showed no significant variations at any time point. No significant change in host cell population could be observed. Since the measured G2/M population never increased to more than 3% of the total cell population, the change observed in the 31P NMR spectra were not simply the result of possible differences in NMR profiles of the different cell phase populations but were more likely due to a change in the metabolic characteristics or environment of a majority of the cells.

Influence of hip prostheses on high energy photon dose distributions

Radiotherapy treatment of patients having a hip prosthesis is a common problem facing dosimetrists and physicists when the treatment plan requires irradiation of the pelvic area. To quantify the perturbation of these devices, attenuation studies were done with 6 and 18 MV photon beams using various hip prostheses models with varying size and composition. These studies have shown that an attenuation of as much as 50% can be found in a single beam profile under the prosthesis. We have studied the capability of a dose planning system to predict the transmission of these devices as compared with measurements.

Use of ferroelectric-crystal detectors for electron dosimetry

A ferroelectric detector system was designed for measurement of dose rate in high-energy electron beams. It was found that a simple lead zirconate-titanate ceramic responds reproducibly to a chopped electron beam by ferroelectric conversion of the resulting pulsed temperature rise to a proportional output voltage. Response as a function of dose rate is linear, the rate of response being a function of incident energy. As a calorimetric dose-rate meter the detector is responsive with response improving as energy is reduced. The detector can be used over a broad range of energies not usually accessible with a single detector.

Clonogenic cells and rat mammary cancer: effects of hormones, X rays, and fission neutrons

On Day 0, young adult female F344 rats were adrenalectomized and intrasplenically implanted with a pituitary gland and capsule containing estrone. All were thereafter given 2.5 mg deoxycorticosterone per week and the choice of saline or tap water. This treatment yields high prolactin levels and glucocorticoid deficiency (Prl+/Glc-). On Day +48, total recoverable mammary DNA was increased by more than sevenfold, tritiated thymidine uptake by nearly fourfold, and total mammary clonogens by about fivefold. Irradiation with 4, 40, and 80 cGy X rays on Day +48 increased total mammary carcinomas per rat day at risk linearly with dose, and 40 and 80 cGy significantly decreased first carcinoma latency. A dose of 40 cGy X rays on Day -1 yielded tumor latencies and frequencies insignificantly different from unirradiated controls and significantly different from the dose on Day +48. Total carcinomas per rat day at risk were better fit by a function of dose to the power 0.4 than by a linear function after exposure to 1, 10, and 20 cGy fission neutrons, and 10 and 20 cGy significantly shortened the time to appearance of the first cancer. In contrast to results with X rays, 10 cGy neutrons on Day -1 yielded tumor frequencies and latencies insignificantly different from 10 cGy neutrons on Day +48. The carcinogenic action of X rays was thus influenced by total clonogen numbers and/or proliferation rates; that of neutrons was not.

Scatter factor corrections for elongated fields

Measurements have been made to determine scatter factor corrections for elongated fields of Cobalt-60 and for nominal linear accelerator energies of 6 MV (Siemens Mevatron 67) and 18 MV (AECL Therac 20). It was found that for every energy the collimator scatter factor varies by 2% or more as the field length-to-width ratio increases beyond 3:1. The phantom scatter factor is independent of which collimator pair is elongated at these energies. For 18 MV photons it was found that the collimator scatter factor is complicated by field-size-dependent backscatter into the beam monitor.

Less well known parameters of in vitro radiosensitivity

In addition to well known parameters used for measuring in vitro cellular radiosensitivity (mean lethal dose, extrapolation number, quasithreshold dose), there are other, less well known measures that may be more important. The authors recently surveyed the literature and found that mean activation dose (D) has been neglected in the analyses. Among 70 articles published in the radiation oncology and biology literature that used cell survival curves or parameters to measure radiosensitivity, only two used the values of D in their analysis. By recalculating D from published survival curves, different conclusions may be drawn. The authors see a definite need for more prospective application of D and surviving fraction at 2 Gy.

Application of thermal dilution measurements for thermal treatment planning

The use of thermal dilution measurements is demonstrated in quantifying effective thermal conductivity distributions through tumours. For focused acoustic sources these data are applied in the solution of the heat diffusion equation to estimate steady-state temperature distributions. The advantages and disadvantages of this approach are presented. The effective conductivity measurements are found to be useful in predicting the circumstances under which this simple model can be applied and in aiding the selection of the most appropriate heating modality.

Thermal modeling in cylindrical coordinates using effective conductivity

Predictive thermometry, utilizing minimally invasive sampling techniques, is an essential ingredient in the development of hyperthermia treatment planning capabilities. The authors demonstrate a powerful, but simple approach toward predicting temperature distributions in tissues, based on analytic solution, using in cylindrical symmetry, of the heat diffusion equation. Conduction and localized perfusion effects are combined as an effective conductivity term, readily measurable, and parametrized in a general exponential form. The proposed approach allows a first-order approximation to modeling three typical situations: hypoxic or necrotic tumor core with homogeneously perfused periphery; highly perfused periphery (in rapidly growing tumors); or perfused central cover with a less well-supplied periphery (such as for some invasive tumors). The utility and strength of this approach is that it provides a rapid, accurate model of directly observing the technical quality to be expected for different heating methods, making it possible to optimally configure source distributions in a treatment planning setting.

Posterior spinal cord block: a dosimetric study

To determine the optimal width of a midline posterior spinal block (MPSB) (to avoid delivering too great a dose to the cord and too small a dose to adjacent tissue), the authors determined with magnetic resonance (MR) imaging normal ranges of cord depth and width and correlated them with film dosimetric data. In 59 randomly selected patients there was a wide range for both depth and width. The average depths of the anterior and posterior surfaces of the cord were 6.7 cm +/- 1.4 and 5.4 cm +/- 1.3, respectively. The average cord width was 1.6 cm +/- 0.4. Optimal cord block width as a function of cord width was determined for a 6-MV photon beam. The optimal cord block width at the surface (half-value layer [HVL] thickness = 6) varied from 1.5 to 3.0 cm for cord widths of 0.8-2.4 cm, which correspond to two standard deviations from the average. There was no significant dependence on depth of the cord. For optimal treatment outcome, the MPSB width may have to be determined for each patient individually.

Thermal dosimetry of normal porcine tissue

The response of normal porcine fat and muscle to graduated doses of hyperthermia provided by an annularly focused acoustic source was measured. Temperatures and exposure times were varied between 43 degrees C (20-90 min), 45 and 47 degrees C (20-60 min), and 49 degrees C (20 min). Response, based on histologic grading of the treated sites 30 days after exposure, was found to correlate well when mapped against several methods of estimating thermal energy deposition. The threshold for damage production was at or near 43 degrees C. For a given temperature, a nearly exponential increase in relative tissue damage as a function of increased exposure time was found. A twofold increase in tissue damage was produced in fat relative to muscle at any given thermal dose.

Chronic response of normal porcine fat and muscle to focused ultrasound hyperthermia

Annular focused ultrasound (1.13 MHz) hyperthermia was used to evaluate chronic histologic effects of a range of high thermal dosages on normal porcine tissues. The effects of three peak temperatures (45, 47, and 49 degrees C) at a focal depth of 2 cm in thirty 4-cm-diameter sites were studied as a function of exposure time (10-60 min). Relative fat and muscle damage were histologically graded 1 month post-treatment. Unlike reports of radiofrequency hyperthermia, no necrosis or abscess formation was observed, even at 49 degrees C for 40 min. Fat sustained a greater percentage maximal tissue damage than muscle, although less than 4% of sections evaluated had histologic evidence of severe injury. Focused ultrasound provides a relatively uniform heat distribution in normal tissues. It should therefore be possible to raise normal tissues surrounding tumors to high temperatures using focused ultrasound, potentiating tumoricidal effects with minimal associated complications.

Determination of contamination-free build-up for 60Co

Experimental verification of the difference between absorbed dose in tissue and the collision fraction of kerma requires precise knowledge of the absorbed dose curve, particularly in the build-up and build-down regions. A simple method for direct measurement of contamination-free build-up for 60Co, which should also be applicable for most of the photon energies commonly employed for treatment, is presented. It is shown that the contribution from air-scattered electrons to the surface dose may be removed by extrapolating measurements of build-up to zero field size. The remaining contribution to contamination from the collimators and other source-related hardware may be minimised by measuring these build-up curves sufficiently far from the source. These results were tested by measuring the build-up using a magnet to sweep scattered electrons from the primary photon beam and by measuring the surface dose in the limit of an evacuated beam path. The relative dose at zero depth in polystyrene was found to be approximately 8.9 +/- 0.3% of the dose at the depth of maximum build-up.

Versatility of distributed focus ultrasound in treatment of superficial lesions

In order to study the efficacy of hyperthermia as a cancer treatment modality, it is important to be able to define the specific volume being raised to hyperthermic temperatures corresponding to the selected method of heating. Measurements have been made of temperature distributions in rat mammary tumors during steady state heating with annular focused ultrasound (2.0 MHz). Biological response in terms of growth inhibition is compared with uniformity of induced temperature throughout the tumors as a function of annular focusing dimensions.

Effect of pulsed dose in simultaneous and sequential irradiation of V-79 cells by 14.8-MeV neutrons and 60Co photons

The effect of irradiating V-79 Chinese hamster cells with a mixture of 40% 14.8-MeV neutrons and 60% 60Co photons with simultaneous or sequential exposures is investigated. Sample doses are obtained by irradiating cells with alternating 3-min pulses of neutrons and photons (in the sequential case) or with mixed neutrons and photons followed by equal beam-off periods to ensure equal total exposure times for sequential and simultaneous irradiations. Differences between the survival results under each beam configuration that are consistent with previous observations with nonpulsed irradiations are observed.

Performance characteristics of A 150 plastic-equivalent gases in A 150 plastic proportional counters for 14.8-MeV neutrons

Two recently developed A 150 plastic-equivalent gas mixtures have been tested for suitability in proportional counter applications. Methane- and propane-based "tissue-equivalent" gases were also included for comparison purposes. Event-size weighted dose distributions were measured in a 14.8-MeV neutron beam. Resolution was found to be independent of gas mixture. Moreover the gains of the two A 150 mixtures were the same, and comparable to that of the methane-based gas mixture. The ionization yield per event size was also independent of the hydrogenous gas mixture employed. Neutron doses determined with the proportional counter were in reasonable agreement with those obtained from an ionization chamber.

Calculational methods for estimating skin dose from electrons in Co-60 gamma-ray beams

Several methods have been employed to calculate the relative contribution to skin dose due to scattered electrons in Co-60 gamma-ray beams. Either the Klein-Nishina differential scattering probability is employed to determine the number and initial energy of electrons scattered into the direction of a detector, or a Gaussian approximation is used to specify the surface distribution of initial pencil electron beams created by parallel or diverging photon fields. Results of these calculations are compared with experimental data. In addition, that fraction of relative surface dose resulting from photon interactions in air alone is estimated and compared with data extrapolated from measurements at large source-surface distance (SSD). The contribution to surface dose from electrons generated in air is 50% or more of the total skin dose for SSDs greater than 80 cm.

V79 survival following simultaneous or sequential irradiation by 15-MeV neutrons and 60Co photons

A unique tandem source irradiation facility, composed of an intense d-T neutron source and a 60Co teletherapy unit, was used to investigate biological responses for different neutron/photon configurations. V79 Chinese hamster cells, attached as monolayers in log-phase growth, were irradiated at 37 degrees C by either 14.8-MeV neutrons, 60Co, or a mixture of 40% neutrons and 60% photons in simultaneous or sequential application. Measurements of cell survival indicate an increased effectiveness in cell killing for simultaneously administered neutrons and photons compared to that measured or predicted for sequentially applied beam modalities. An understanding of the magnitude of these interactive effects is important both for calculating accurate effective doses for neutron radiotherapy of deep-seated tumors, for which the photon component is appreciable, and for determination of environmental hazards to people occupationally exposed to mixtures of photons and neutrons.