Myxofibrosarcoma: Outcomes, Prognostic Factors, and Role of Neoadjuvant Radiation Therapy

Purpose

Myxofibrosarcoma (MFS) is a subtype of soft tissue sarcoma with a highly infiltrative growth pattern that leads to a higher risk of inadvertent positive surgical margins and local relapse. Poorly defined tumor margins also pose a challenge for radiation therapy (RT) planning, in terms of treatment volumes and administration of pre- versus postoperative RT. This study aims to evaluate local control and patterns of recurrence in patients with MFS treated with neoadjuvant RT followed by definitive surgical excision.

Methods and Materials

Multiple institutional databases were retrospectively searched for patients diagnosed with MFS between 2013 and 2021 who were exclusively treated with preoperative RT followed by definitive surgery at our institution. The endpoints of the study were defined as local tumor recurrence, distant metastasis, and death after the date of definitive surgery.

Results

Forty-nine patients met the inclusion criteria and were included in the final study. The median age at diagnosis was 67 years, and 71% of patients were male. The tumor was superficially located in 63% of patients, and the mean tumor size at presentation was 7.8 cm. All patients received neoadjuvant RT and completed their planned course of treatment. Neoadjuvant chemotherapy was administered in 22% of patients. Inadvertent excision (IE) before definitive treatment was performed in 25 patients (51%), 84% of which had superficially located tumors. All margins were assessed using frozen section analysis at the time of definitive surgery, and 100% of patients had negative surgical margins, with 25% having no residual tumor. With a median follow-up of 4.7 years, the 5-year local control rate was 87%, and 5-year overall survival was 98%. Tumor depth was associated with distant metastasis (P < .01).

Conclusions

Despite the infiltrative nature of MFS, preoperative RT followed by definitive surgical excision, especially in the setting of a reliable frozen section margin analysis, was associated with excellent local control.

Automated target placement for VMAT lattice radiation therapy: enhancing efficiency and consistency

Objective. An algorithm was developed for automated positioning of lattice points within volumetric modulated arc lattice radiation therapy (VMAT LRT) planning. These points are strategically placed within the gross tumor volume (GTV) to receive high doses, adhering to specific separation rules from adjacent organs at risk (OARs). The study goals included enhancing planning safety, consistency, and efficiency while emulating human performance.Approach. A Monte Carlo-based algorithm was designed to optimize the number and arrangement of lattice points within the GTV while considering placement constraints and objectives. These constraints encompassed minimum spacing between points, distance from OARs, and longitudinal separation along thez-axis. Additionally, the algorithm included an objective to permit, at the user's discretion, solutions with more centrally placed lattice points within the GTV. To validate its effectiveness, the automated approach was compared with manually planned treatments for 24 previous patients. Prior to clinical implementation, a failure mode and effects analysis (FMEA) was conducted to identify potential shortcomings.Main results.The automated program successfully met all placement constraints with an average execution time (over 24 plans) of 0.29 ±0.07 min per lattice point. The average lattice point density (# points per 100 c.c. of GTV) was similar for automated (0.725) compared to manual placement (0.704). The dosimetric differences between the automated and manual plans were minimal, with statistically significant differences in certain metrics like minimum dose (1.9% versus 1.4%), D5% (52.8% versus 49.4%), D95% (7.1% versus 6.2%), and Body-GTV V30% (20.7 c.c. versus 19.7 c.c.).Significance.This study underscores the feasibility of employing a straightforward Monte Carlo-based algorithm to automate the creation of spherical target structures for VMAT LRT planning. The automated method yields similar dose metrics, enhances inter-planner consistency for larger targets, and requires fewer resources and less time compared to manual placement. This approach holds promise for standardizing treatment planning in prospective patient trials and facilitating its adoption across centers seeking to implement VMAT LRT techniques.

Spatially Fractionated Radiation Therapy in Sarcomas: A Large Single-Institution Experience

Purpose

Spatially fractionated radiation therapy (SFRT) is a recognized technique for enhancing tumor response in radioresistant and bulky tumors. We analyzed clinical and treatment outcomes in patients with bone and soft tissue sarcomas treated with modern SFRT techniques.

Methods and Materials

Patients with metastatic or unresectable sarcoma treated with brass collimator, volumetric modulated arc therapy lattice, or proton SFRT from December 2019 to June 2022 were retrospectively reviewed. Consolidative external beam radiation therapy (EBRT) was delivered at the physician's discretion. Patient and treatment characteristics, treatment response (symptom improvement, local control, and imaging response), and toxicity data were collected.

Results

The cohort consisted of 53 patients treated with 61 SFRT treatments. Median age at treatment was 60.0 years. The primary location was soft tissue in 46 courses (75%) and bone in 15 (25%). Fifty-three courses (87%) were treated for symptom relief. The most used SFRT technique was volumetric modulated arc therapy lattice (n = 52, 85%) to a dose of 20 Gy (n = 48, 79%; range, 16-20 Gy). EBRT was delivered post-SFRT in 55 (90%) treatment courses with a median time interval from SFRT to EBRT of 5 days (range, 0-14 days). Median physical EBRT dose and fractionation was 40 Gy (range, 9-73.5 Gy) and 10 fractions (range, 3-33 fractions). Median follow up was 7.4 months (range, 0.2-30 months). One-year overall survival and local control rates were 53% and 82%. Symptom relief was documented with 32 treatment courses (60%). Stable or partial response was observed with 47 treatment courses (90%). Four grade 3 to 4 acute and subacute toxicities were attributable to SFRT (8%).

Conclusions

The current series is the largest to date documenting outcomes for SFRT in sarcomas. Our results suggest combined SFRT with EBRT is associated with a favorable toxicity profile and high rates of symptomatic and radiographic responses for metastatic or unresectable sarcomas.

The Pediatric Proton and Photon Therapy Comparison Cohort: Study Design for a Multicenter Retrospective Cohort to Investigate Subsequent Cancers After Pediatric Radiation Therapy

Purpose

The physical properties of protons lower doses to surrounding normal tissues compared with photons, potentially reducing acute and long-term adverse effects, including subsequent cancers. The magnitude of benefit is uncertain, however, and currently based largely on modeling studies. Despite the paucity of directly comparative data, the number of proton centers and patients are expanding exponentially. Direct studies of the potential risks and benefits are needed in children, who have the highest risk of radiation-related subsequent cancers. The Pediatric Proton and Photon Therapy Comparison Cohort aims to meet this need.

Methods and Materials

We are developing a record-linkage cohort of 10,000 proton and 10,000 photon therapy patients treated from 2007 to 2022 in the United States and Canada for pediatric central nervous system tumors, sarcomas, Hodgkin lymphoma, or neuroblastoma, the pediatric tumors most frequently treated with protons. Exposure assessment will be based on state-of-the-art dosimetry facilitated by collection of electronic radiation records for all eligible patients. Subsequent cancers and mortality will be ascertained by linkage to state and provincial cancer registries in the United States and Canada, respectively. The primary analysis will examine subsequent cancer risk after proton therapy compared with photon therapy, adjusting for potential confounders and accounting for competing risks.

Results

For the primary aim comparing overall subsequent cancer rates between proton and photon therapy, we estimated that with 10,000 patients in each treatment group there would be 80% power to detect a relative risk of 0.8 assuming a cumulative incidence of subsequent cancers of 2.5% by 15 years after diagnosis. To date, 9 institutions have joined the cohort and initiated data collection; additional centers will be added in the coming year(s).

Conclusions

Our findings will affect clinical practice for pediatric patients with cancer by providing the first large-scale systematic comparison of the risk of subsequent cancers from proton compared with photon therapy.

Carbon Ion Radiotherapy: An Evidence-Based Review and Summary Recommendations of Clinical Outcomes for Skull-Base Chordomas and Chondrosarcomas

Skull-base chordoma and chondrosarcoma are rare radioresistant tumors treated with surgical resection and/or radiotherapy. Because of the established dosimetric and biological benefits of heavy particle therapy, we performed a systematic and evidence-based review of the clinical outcomes of patients with skull-base chordoma and chondrosarcoma treated with carbon ion radiotherapy (CIRT). A literature review was performed using a MEDLINE search of all articles to date. We identified 227 studies as appropriate for review, and 24 were ultimately included. The published data illustrate that CIRT provides benchmark disease control outcomes for skull-base chordoma and chondrosarcoma, respectively, with acceptable toxicity. CIRT is an advanced treatment technique that may provide not only dosimetric benefits over conventional photon therapy but also biologic intensification to overcome mechanisms of radioresistance. Ongoing research is needed to define the magnitude of benefit, patient selection, and cost-effectiveness of CIRT compared to other forms of radiotherapy.

Memantine for Pediatric Patients Receiving Cranial Irradiation: A Pilot Study

PURPOSE/OBJECTIVE(S)

While memantine has become standard in certain adults receiving brain RT to decrease the cognitive impacts of RT, it is unknown whether pediatric patients can take and tolerate memantine or experience benefit. In this prospective single-arm feasibility study, we hypothesized pediatric patients receiving brain RT would tolerate memantine with good treatment adherence.

MATERIALS/METHODS

Patients aged 4-18 years with a primary CNS malignancy (excluding WHO Grade IV astrocytoma and glioblastoma) receiving intracranial RT were eligible. A 6-month course of memantine was given during and after RT. Dosing began once daily at 5 mg with up-titration in 5 mg increments over 4 weeks to a weight-based maximum (0.4 mg/kg to the closest 5 mg), not to exceed 10 mg BID. To reduce patient and clinical research associate (CRA) burden, medication adherence was tracked via the Medisafe Pill and Reminder application which study staff helped install on the patient or parent's smart phone. A paper pill diary was provided for those unable to use the app. The primary endpoint was to achieve 80% adherence rate to memantine in 80% of patients measured 1-month post-RT.

RESULTS

Eighteen patients (14 male and 4 female, median age 11.5 years (range: 4-18)) were enrolled from 2020-2022. The study closed early after enrolling 18 of 20 planned patients to avoid competing with the phase III randomized Children's Oncology Group (COG) study AACL2031. One patient withdrew for cognition-altering substance-use, leaving 17 patients with data available for analysis. Histologies included germ cell tumor (n = 6), craniopharyngioma (n = 3), choroid plexus papilloma (n = 2), ependymoma (n = 2), glial/astrocytoma (n = 2), medulloblastoma (n = 1), and meningioma (n = 1). Thirteen had surgery, and 9 received chemotherapy. Eight received craniospinal irradiation (CSI). Median RT dose was 54 Gy (range 36-59.4) in 30 fractions (range: 20-33). At data freeze, all 17 had passed the 1-month post-RT time point. One patient discontinued memantine after a single dose due to nausea. Pill-reports were available for 14 of the remaining 16; two patients did not complete digital pill logs. For those with complete logs, all adherence rates were above 80%, with a median of 99.32% pill completion rate (range: 92.67-100). Seven (50%) took 100% of prescribed doses. Irrespective of adherence for the 2 unavailable for evaluation, the primary endpoint was still achieved. Grade 1 toxicities included headache (n = 6, 35%) and constipation (n = 1, 6%); there were no grade 2+ toxicities. At last follow-up, 15/16 have completed the full 6-month memantine course. Secondary endpoints including neurocognitive evaluations have not yet been met and will be the subject of future reports.

CONCLUSION

Memantine is a feasible and well-tolerated addition to multi-modality treatment for pediatric brain tumors. Secondary endpoints of this study and results of the ongoing COG study are awaited to define the value of memantine in this population.

Clinical Outcomes for Chest Wall Ewing Sarcoma: A Multi-Center Single Institution Experience

PURPOSE/OBJECTIVE(S)

We report tumor and treatment characteristics, oncologic outcomes, and treatment-associated toxicities in a cohort of chest wall Ewing sarcoma (cwES) patients treated at a single tertiary care institution.

MATERIALS/METHODS

After IRB approval, patients with cwES treated from 1997-2022 were retrospectively reviewed. Patient, tumor, treatment, outcomes, and toxicity data were abstracted. Local control (LC), progression-free survival (PFS), and overall survival (OS) were defined from end of treatment and assessed using the Kaplan-Meier method. Log-rank test and unadjusted Cox models were performed to determine factors associated with outcomes.

RESULTS

The cohort includes 45 patients. Median age at diagnosis was 19.8 years (range: 3.5 - 57.8 years). Five patients (11.1%) presented with pleural effusion and eight patients with lung metastases (17.8%). Two (4.4%) patients had metastatic disease outside the thorax. Median tumor volume (TV) was 138.6 mL (range: 3.0-6762.0 mL). All patients received VDC/IE chemotherapy. LC modality was surgery (S) in 21 patients (47%), radiation therapy (RT) in 5 (11%), and S+RT in 19 (42%). Median TV was larger in S+RT patients (319.4 mL, range: 5.3-6761.9 mL) compared to RT (152.3 mL, range: 20.4-366.9 mL) or S (70.4 mL, range: 3.1-1037.8 mL) (p = 0.03). R0 and R1 resections were performed in 36 (90%) and 4 (10%) patients, respectively. Proton beam therapy was used in 15 (63%) patients. Median dose was 50.40 Gy (range: 34.2 - 60 Gy) in 28 fractions to the primary tumor or post operative bed. Median dose for hemithorax (1 patient, 2.2%) and whole lung irradiation (7 patients, 15.6%) was 15.0 Gy (range: 15.0-15.0 Gy) in 10 fractions. Median follow-up was 2.38 years (range: 0 - 21.90 years). Five-year LC, PFS, and OS for all patients was 77.9% (95% CI, 65.3 - 92.9%), 54.2% (95% CI, 39.9 - 73.5%), and 63.5% (95% CI, 49.3 - 81.8%), respectively. In patients with localized disease, 5-year LC, PFS, and OS were 82.4% (95% CI, 67.9-99.8%), 66.4% (95% CI, 49.7-88.8%), and 71.3% (95% CI, 54.2-93.9%), respectively. Two-year LC by modality was 100% for RT (95% CI, 100-100%), 84.2% (95% CI, 69.3- 100%) for S and 73.3% (95% CI, 54 - 99.5%) for S+RT (p = 0.51). On univariate analysis, TV ≥ 200 mL was associated with a significantly worse 5-year OS (49.5%, TV ≥ 200 mL vs. 80.8%, TV < 200 mL; HR 4.44, p = 0.032) and PFS (35.2%, TV ≥ 200 mL vs. 76%, TV < 200 mL; HR 3.55, p = 0.025). TV ≥ 200 mL trended towards worse 5-year LC: 69.2% for TV ≥ 200 mL versus 81.5% for TV <200 mL [HR 2.26(95% CI 0.49 - 10.47), p = 0.287]. Overall, low rates of grade ≥2 toxicity were observed: 4 (8.9%) fatigue, 4 (8.9%) radiation dermatitis, 1 (2.2%) chyle leak, 3 (6.6%) scoliosis, 4 (8.9%) infection, 1 (2.2%) pneumonia, and 1 (2.2%) chest wall deformity.

CONCLUSION

RT is a safe, effective local therapy for small to moderate cwES tumors. Patients with TV ≥ 200 mL had significantly worse survival outcomes and an inferior LC rate. This suggests large cwES tumors may benefit from an aggressive multi-modality approach.

Dose delivery reproducibility for PBS proton treatment of breast cancer patients with and without mask immobilization

BACKGROUND

Setup reproducibility of the tissue in the proton beam path is critical in maintaining the planned clinical target volume (CTV) dose coverage and sparing the organs at risk (OAR). In this study, we retrospectively evaluated radiation therapy dose reproducibility for proton pencil beam scanning (PBS) treatment of breast cancer patients with and without mask immobilization.

METHODS

Ninety-four patients treated between January 2019 and September 2022 with at least one verification CT scan (V-CT) in treatment position were included for this study. All patients were set up with arms up using the Orfit AIO patient positioning system, with (69 patients) or without (25 patients) mask immobilization in chin, neck, shoulder, upper arm, and chest areas. Two to three enface or near enface single field uniform dose PBS beams were optimized using a commercial treatment planning system. Prescription doses were 25 to 60 GyRBE in 5 to 45 fractions. Treatment plan doses re-calculated on V-CTs were compared to the corresponding planned doses. Cumulative doses were also calculated for patients with at least 3 V-CTs by deform and weighted sum doses from V-CTs to corresponding P-CTs. CTV D95%, ipsilateral-lung V40%, esophagus D0.01cc, and heart mean dose were evaluated and reported as percentages of prescription doses. Differences were large dose deteriorations (LDD) if: (1) CTV (V-CT/cumulative D95%) - (Planned D95%) < - 5%; or (2) Ipsilateral-lung (V-CT/cumulative V40%) - (Planned V40%) > 5%; or (3) Esophagus (V-CT/cumulative D0.01cc) - (Planned D0.01cc) > 10%; or (4) Heart (V-CT/cumulative mean) - (Planned mean) > 1.5%.

RESULTS

On average, V-CT/cumulative and planned CTV/OAR dose parameter differences were less than 2.2%/1.7% and 3.4%/3.7% for masked and maskless patients, respectively. The percentages of patients with at least one CTV or OAR V-CT/cumulative dose LDD were 20.3%/25.0% and 72.0%/54.0% for masked and maskless patients, respectively.

CONCLUSIONS

On average, masked/maskless setups achieved delivered and planned CTV/OAR dose parameters agreed within 2.2%/3.7% for PBS treatment of breast cancer patients in this study. Maskless patients had higher rate of CTV/OAR LDDs compared to masked patients. Dosimetric differences large enough to raise clinical concerns in either group were able to be addressed with replannings.

Proton Therapy in the Adolescent and Young Adult Population

BACKGROUND

Adolescent and young adult cancer patients are at high risk of developing radiation-associated side effects after treatment. Proton beam radiation therapy might reduce the risk of these side effects for this population without compromising treatment efficacy.

METHODS

We review the current literature describing the utility of proton beam radiation therapy in the treatment of central nervous system tumors, sarcomas, breast cancer and Hodgkin lymphoma for the adolescent and young adult cancer population.

RESULTS

Proton beam radiation therapy has utility for the treatment of certain cancers in the young adult population. Preliminary data suggest reduced radiation dose to normal tissues, which might reduce radiation-associated toxicities. Research is ongoing to further establish the role of proton therapy in this population.

CONCLUSION

This report highlights the potential utility of proton beam radiation for certain adolescent young adult cancers, especially with reducing radiation doses to organs at risk and thereby potentially lowering risks of certain treatment-associated toxicities.

Trimodality Therapy Improves Disease Control in Radiation-Associated Angiosarcoma of the Breast

PURPOSE

To evaluate the impact of trimodality treatment versus monotherapy or dual therapy for radiation-associated angiosarcoma of the breast (RAASB) after prior breast cancer treatment.

EXPERIMENTAL DESIGN

With Institutional Review Board approval, we identified patients diagnosed with RAASB and abstracted data on disease presentation, treatment, and oncologic outcomes. Trimodality therapy included (i) taxane induction, (ii) concurrent taxane/radiation, and then (iii) surgical resection with wide margins.

RESULTS

A total of 38 patients (median age 69 years) met inclusion criteria. Sixteen received trimodality therapy and 22 monotherapy/dual therapy. Skin involvement and disease extent were similar in both groups. All trimodality patients required reconstructive procedures for wound closure/coverage, compared with 48% of monotherapy/dual therapy patients (P < 0.001). Twelve of 16 (75%) patients receiving trimodality therapy had a pathologic complete response (pCR). With median follow-up of 5.6 years, none had local recurrence, 1 patient (6%) had distant recurrence, and no patients died. Among 22 patients in the monotherapy/dual therapy group, 10 (45%) had local recurrence, 8 (36%) had distant recurrence, and 7 (32%) died of disease. Trimodality therapy demonstrated significantly better 5-year recurrence-free survival [RFS; 93.8% vs. 42.9%; P = 0.004; HR, 7.6 (95% confidence interval, CI: 1.3-44.2)]. Combining all patients with RAASB regardless of treatment, local recurrence was associated with subsequent distant recurrence (HR, 9.0; P = 0.002); distant recurrence developed in 3 of 28 (11%) patients without local recurrence compared with 6 of 10 (60%) with local recurrence. The trimodality group had more surgical complications that required reoperation or prolonged healing.

CONCLUSIONS

Trimodality therapy for RAASB was more toxic but is promising, with a high rate of pCR, durable local control, and improved RFS.

Long-term outcomes of intraoperatively-placed applicator brachytherapy for rapid completion of breast conserving treatment: An analysis of a prospective registry data

Background and purpose

To evaluate the long-term outcome of accelerated partial breast irradiation utilizing intraoperatively placed applicator-based brachytherapy (ABB) in early-stage breast cancer.

Materials and methods

From our prospective registry, 223 patients with pTis-T2, pN0/pN1mic breast cancer were treated with ABB. The median treatment duration including surgery and ABB was 7 days. The prescribed doses were 32 Gy/8 fx BID (n = 25), 34 Gy/10 fx BID (n = 99), and 21 Gy/3 fx QD (n = 99). Endocrine therapy (ET) adherence was defined as completion of planned ET or ≥ 80% of the follow-up (FU) period. Cumulative incidence of ipsilateral breast tumor recurrence (IBTR) was estimated and influencing factors for IBTR-free survival rate (IBTRFS) were analyzed.

Results

218/223 patients had hormone receptor-positive tumors, including 38 (17.0%) with Tis and 185 (83.0%) with invasive cancer. After a median FU of 63 months, 19 (8.5%) patients had recurrence [17 (7.6%) with an IBTR]. Rates of 5-year IBTRFS and DFS were 92.2% and 91.1%, respectively. The 5-year IBTRFS rates were significantly higher for post-menopausal women (93.6% vs. 66.4%, p = 0.04), BMI < 30 kg/m2 (97.4% vs. 88.1%, p = 0.02), and ET-adherence (97.5% vs. 88.6%, p = 0.02). IBTRFS did not differ with dose regimens.

Conclusions

Postmenopausal status, BMI < 30 kg/m2, and ET- adherence predicted favorable IBTRFS. Our results highlight the importance of careful patient selection for ABB and encouragement of ET compliance.

Clinical aspects of spatially fractionated radiation therapy treatments

PURPOSE

To provide clinical guidance for centers wishing to implement photon spatially fractionated radiation therapy (SFRT) treatments using either a brass grid or volumetric modulated arc therapy (VMAT) lattice approach.

METHODS

We describe in detail processes which have been developed over the course of a 3-year period during which our institution treated over 240 SFRT cases. The importance of patient selection, along with aspects of simulation, treatment planning, quality assurance, and treatment delivery are discussed. Illustrative examples involving clinical cases are shown, and we discuss safety implications relevant to the heterogeneous dose distributions.

RESULTS

SFRT can be an effective modality for tumors which are otherwise challenging to manage with conventional radiation therapy techniques or for patients who have limited treatment options. However, SFRT has several aspects which differ drastically from conventional radiation therapy treatments. Therefore, the successful implementation of an SFRT treatment program requires the multidisciplinary expertise and collaboration of physicians, physicists, dosimetrists, and radiation therapists.

CONCLUSIONS

We have described methods for patient selection, simulation, treatment planning, quality assurance and delivery of clinical SFRT treatments which were built upon our experience treating a large patient population with both a brass grid and VMAT lattice approach. Preclinical research and patient trials aimed at understanding the mechanism of action are needed to elucidate which patients may benefit most from SFRT, and ultimately expand its use.

Dosimetric comparison between proton beam therapy, intensity modulated radiation therapy, and 3D conformal therapy for soft tissue extremity sarcoma

PURPOSE/OBJECTIVES

Proton beam therapy (PBT) may provide a dosimetric advantage in sparing soft tissue and bone for selected patients with extremity soft sarcoma (eSTS). We compared PBT with photons plans generated using intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT).

MATERIALS/METHODS

Seventeen patients previously treated with pencil beam scanning PBT were included in this study. Of these patients, 14 treated with pre-operative 50 Gy in 25 fractions were analyzed. IMRT and 3D-CRT plans were created to compare against the original PBT plans. Dose-volume histogram (DVH) indices were evaluated amongst PBT, IMRT, and 3D plans. Kruskal-Wallis rank sum tests were used to get the statistical significance. A p value smaller than .05 was considered to be statistically significant.

RESULTS

For the clinical target volume (CTV), D2%, D95%, D98%, D_min, D_max, and V50Gy, were assessed. D_min, D1%, D_max, D_mean, V1Gy, V5Gy, and V50Gy were evaluated for the adjacent soft tissue. D1%, D_max, D_mean, and V35-50% were evaluated for bone. All plans met CTV target coverage. The PBT plans delivered less dose to soft tissue and bone. The mean dose to the soft tissue was 2 Gy, 11 Gy, and 13 Gy for PBT, IMRT, and 3D, respectively (p < .001). The mean dose to adjacent bone was 15 Gy, 26 Gy, and 28 Gy for PBT, IMRT, and 3D, respectively (p = .022).

CONCLUSION

PBT plans for selected patients with eSTS demonstrated improved sparing of circumferential soft tissue and adjacent bone compared to IMRT and 3D-CRT. Further evaluation will determine if this improved dosimetry correlates with reduced toxicity and improved quality of life.

Lack of radiosensitivity predicts poor disease specific survival in myxoid liposarcoma

BACKGROUND

Compared to other sarcomas, myxoid liposarcoma (ML) is known to be radiosensitive, with improved oncologic outcomes. Although these tumors "shrink" following radiotherapy, there is a paucity of data examining the degree of radiosensitivity and oncologic outcome. The purpose of the study was to evaluate pre- and postradiotherapy tumor volume to determine if size reduction impacts outcome.

METHODS

We reviewed 62 patients with ML undergoing surgical resection combined with preoperative radiotherapy, with pre- and postradiotherapy MRI. This included 34 (55%) males, with a mean age of 47 ± 14 years. All tumors were deep to the fascia, and 12 (19%) patients had tumors with a >5% round-cell component.

RESULTS

The mean volume reduction was 54% ± 29%. Compared to patients with >25% volume reduction, patients with reduction ≤25% had worse 10-year disease specific survival (86% vs. 37%, p < 0.01), in addition to an increased risk of metastatic disease (HR 4.63, p < 0.01) and death due to disease (HR 4.52, p < 0.01).

CONCLUSION

Lack of volume reduction is a risk factor for metastatic disease and subsequent death due to disease in patients with extremity ML treated with combined preoperative radiotherapy and surgery. This data could be used to stratify patients for adjuvant therapies and follow-up intervals.

Treatment outcomes of extraskeletal Ewing sarcoma

PURPOSE

Extraskeletal Ewing sarcoma (EES), is a rare soft tissue sarcoma. Treatment for EES commonly involves chemotherapy and surgical resection (ST) or less commonly combined chemotherapy, surgery, and radiotherapy (ST + RT). The purpose of the current study was to evaluate our institutional experience treating EES.

METHODS

We reviewed 36 (18 males:18 females) patients (mean age 30 years) with a nonretroperitoneal/visceral EES treated with either ST (n = 24, 67%) or ST + RT (n = 12, 33%). All patients were treated with chemotherapy, most commonly vincristine, doxorubicin, cyclophosphamide/ifosfamide and etoposide (VDC/IE, n = 23, 66%) Radiotherapy was mostly delivered preoperatively (n = 9). The mean follow-up was 8 years.

RESULTS

The 10-year disease specific survival for patients was 78%, with no difference in the survival between patients in the ST versus the ST + RT groups (83% vs. 71%, p = 0.86). There was no difference in the 10-year local recurrence (91% vs. 100%, p = 0.29) or metastatic free survival (87% vs. 75%, p = 0.45) between the ST and ST + RT groups.

CONCLUSION

The results of the current study highlight the ability to achieve excellent local control with chemotherapy and surgery for EES. We recommend for multidisciplinary management of patients with EES, including chemotherapy and surgery, with use of radiotherapy if there is concern for a potentially close margin of resection.

Proton Whole-Lung Irradiation: Initial Report of Outcomes

PURPOSE

Whole-lung irradiation is typically used in pediatric patients to decrease the risk of future lung metastases, but radiation dose to normal tissue is associated with long-term risks. Proton whole-lung irradiation (PWLI) provides an opportunity to decrease radiation dose to normal tissue and potentially decrease late toxicity.

METHODS AND MATERIALS

This retrospective study included patients treated with spot-scanning PWLI at a single institution. Toxicity and oncologic outcomes were reviewed. Intensity modulated radiation therapy (IMRT) plans were created prospectively or retrospectively for dosimetric comparisons. Simple paired t tests were performed to assess differences between IMRT and PWLI dosimetric parameters.

RESULTS

Twelve patients treated with PWLI were included in this study. Median age was 15 years (range, 3-34). Most (75%) had Ewing sarcoma. Most (92%) received 15 Gy in 10 fractions PWLI, and 3 (25%) received a focal pulmonary boost. Median follow-up was 16.5 months (range, 0-40.4 months). At last follow-up, 1 patient died of disease, while 11 were still alive (7 without disease, 4 with ongoing disease). During and immediately after treatment, 5 patients developed fatigue, 2 patients developed cough, and 1 patient developed nausea. Each treatment-related adverse event was Common Terminology Criteria for Adverse Events (version 5.0) grade 1 and resolved within 3 weeks of treatment completion. No patients have experienced clinical or radiographic pneumonitis or evidence of clinically apparent cardiac toxicity. Compared with IMRT plans, PWLI decreased mean dose to the heart, coronary artery, cardiac valve, left ventricle, aorta, breast, esophagus, kidney, liver, pancreas, thyroid, stomach, and spleen (all P < .001), without sacrificing target coverage.

CONCLUSIONS

PWLI is feasible to deliver, decreases dose to normal tissue compared with IMRT, and appears to be well-tolerated. PWLI provides potential for decreased late toxicity and merits further investigation.

Pragmatic, Prospective Comparative Effectiveness Trial of Carbon Ion Therapy, Surgery, and Proton Therapy for the Management of Pelvic Sarcomas (Soft Tissue/Bone) Involving the Bone: The PROSPER Study Rationale and Design

Surgical treatment of pelvic sarcoma involving the bone is the standard of care but is associated with several sequelae and reduced functional quality of life (QOL). Treatment with photon and proton radiotherapy is associated with relapse. Carbon ion radiotherapy (CIRT) may reduce both relapse rates and treatment sequelae. The PROSPER study is a tricontinental, nonrandomized, prospective, three-arm, pragmatic trial evaluating treatments of pelvic sarcoma involving the bone. Patients aged at least 15 years are eligible for inclusion. Participants must have an Eastern Cooperative Oncology Group Performance Status score of two or less, newly diagnosed disease, and histopathologic confirmation of pelvic chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma with bone involvement, rhabdomyosarcoma (RMS) with bone involvement, or non-RMS soft tissue sarcoma with bone involvement. Treatment arms include (1) CIRT (n = 30) delivered in Europe and Asia, (2) surgical treatment with or without adjuvant radiotherapy (n = 30), and (3) proton therapy (n = 30). Arms two and three will be conducted at Mayo Clinic campuses in Arizona, Florida, and Minnesota. The primary end point is to compare the 1-year change in functional QOL between CIRT and surgical treatment. Additional comparisons among the three arms will be made between treatment sequelae, local control, and other QOL measures.

Analysis of Local Control Outcomes and Clinical Prognostic Factors in Localized Pelvic Ewing Sarcoma Patients Treated With Radiation Therapy: A Report From the Children's Oncology Group

PURPOSE

To identify potential clinical prognostic factors associated with a higher risk of local recurrence in patients with localized pelvic Ewing sarcoma treated with radiation therapy.

METHODS AND MATERIALS

Data for 101 patients treated with definitive radiation therapy (RT) or both surgery and radiation (S + RT) to primary pelvic tumors on INT-0091, INT-0154, and AEWS0031 were analyzed. Imaging data for patients who did not receive radiation were not available for central review; therefore, patients with surgery alone were not included. Cumulative incidence rates for local failure at 5 years from time of local control were calculated accounting for competing risks.

RESULTS

The most common pelvic subsite was sacrum (44.6%). RT was used in 68% of patients and S + RT in 32%. The local failure rate was 25.0% for RT and 6.3% for S + RT (P = .046). There was no statistically significant difference in local control modality by tumor characteristics. Tumors originating in the ischiopubic-acetabulum region were associated with the highest local failure incidence, 37.5% (P = .02, vs sacrum and iliac/buttock tumors), particularly those treated with RT (50.0%, P = .06). A higher incidence of local failure was seen with each additional 100 mL of tumor at diagnosis (P = .04). Multivariable analysis demonstrated RT alone (hazard ratio [HR], 5.1; P = .04), tumor subsite (particularly ischiopubic-acetabulum tumors; HR 4.6; P = .02), and increasing volume per 100 mL (HR, 1.2; P = .01) were associated with a higher incidence of local recurrence.

CONCLUSIONS

Combination surgery and RT is associated with improved local control in patients with pelvic Ewing sarcoma compared with definitive RT. Tumors involving the ischiopubic-acetabulum region and increasing tumor volume at diagnosis are associated with inferior local control. Tumor characteristics did not correlate with choice of local therapy modality suggesting an opportunity to develop best local therapy practices guidelines for future studies based on tumor features.

Patient vs. Caregiver: Correlation and Differences in Pediatric Quality of Life (PedsQL) Using a Prospective Registry in a Large-Volume, Multi-Site Practice

PURPOSE

Patient reported outcomes (PROs) provide quality of life (QOL) data during and after radiation. When pediatric patients are unable to complete PROs, it is unknown whether caregiver responses are an accurate surrogate. We assessed whether caregiver scores for the Pediatric Quality of Life Inventory (PedsQL) Core and Brain Tumor Module questionnaires can substitute for missing child scores.

METHODS AND MATERIALS

From 2016-2018, pediatric patients treated with radiation were followed in a prospective, institutional registry. Child and caregiver Core and Tumor PedsQL surveys were obtained at pre-treatment, end of treatment, and in regular follow-up. The differences between the two scores at each time point were quantified using a linear mixed-model (LMM) while the level of agreement was estimated with intraclass correlation (ICC). An ICC 95% confidence interval lower limit exceeding 0.75 was considered an acceptable threshold for using caregiver scores as imputed values for missing child scores.

RESULTS

Ninety-one children completed 403 surveys. Caregivers underestimated QOL scores at baseline, but not at end of treatment or any follow-up time. The PedsQL Core total score had an ICC of 0.88 (95% CI: 0.81-0.92), while the emotional, physical, school, and social function subdomain scores were 0.81 (0.72-0.88), 0.72 (0.58-0.82), 0.79 (0.68-0.86), and 0.75 (0.62-0.83), respectively. The Tumor total score ICC was 0.91 (0.85, 0.94), and each of the subdomains (cognitive problems, communication, movement and balance, nausea, pain and hurt, perceived physical appearance, procedural anxiety, treatment anxiety, and worry) had ICC lower bound 95% CI ≥ 0.75 except for communication (0.83, 0.74-0.89). Bland-Altman analysis demonstrated no visual change in discrepancy between child and caregiver estimates as overall QOL improved.

CONCLUSION

Agreement between child and caregiver-reported QOL was generally strong in the acute period after radiation, implying that caregiver scores may be imputed for child scores in future protocols and analyses of pediatric QOL.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Comparison of Oncologic Outcomes and Treatment-Related Toxicity of Carbon Ion Radiotherapy and En Bloc Resection for Sacral Chordoma

IMPORTANCE

Maximal resection is the preferred management for sacral chordomas but can be associated with unacceptable morbidity. Outcomes with radiotherapy are poor. Carbon ion radiotherapy (CIRT) is being explored as an alternative when surgery is not preferred.

OBJECTIVE

To compare oncologic outcomes and treatment-related toxicity of CIRT and en bloc resection for sacral chordoma.

DESIGN, SETTING, AND PARTICIPANTS

Univariable logistic regression was performed to evaluate the association between treatment type and oncologic and toxicity outcomes in this retrospective cohort study. Nearest-neighbor propensity score matching was used to match the CIRT cohort with the en bloc resection cohort and 10 National Cancer Database (NCDB) cohorts separately, with the objective of obtaining more homogeneous cohorts when comparing treatments. Patient- and tumor-related characteristics from 2 institutional cohorts were collected for patients diagnosed with sacral chordomas between April 1, 1994, and July 31, 2017. The NCDB was queried for data on patients with sacral chordoma from January 1, 2004, to December 31, 2016, as a comparator in overall survival (OS) analyses. Data analysis was conducted from February 24, 2020, to January 16, 2021.

EXPOSURES

En bloc resection, incomplete resection, photon radiotherapy, proton radiotherapy, and CIRT.

MAIN OUTCOMES AND MEASURES

Overall survival was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model. Peripheral motor nerve toxic effects were scored using Common Terminology Criteria for Adverse Events, version 4.03.

RESULTS

A total of 911 patients were included in the study (NCDB: n = 669; median age, 64 [IQR, 52-74] years; 410 [61.3%] men; CIRT: n = 188; median age, 66 [IQR, 58-71] years; 128 [68.1%] men; en bloc surgical resection: n = 54; median age, 53.5 [IQR 49-64] years, 36 [66.7%] men). Comparison of the propensity score-matched institutional en bloc resection and CIRT cohorts revealed no statistically significant difference in OS (CIRT: median OS, 68.1 [95% CI, 44.0-102.6] months; en bloc resection: median OS, 58.6 [95% CI, 25.6-123.5] months; P = .57; hazard ratio, 0.71 [95% CI, 0.25-2.06]; P = .53). The CIRT cohort experienced lower rates of peripheral motor neuropathy (odds ratio, 0.13 [95% CI, 0.04-0.40]; P < .001). On comparison of the propensity score-matched NCDB cohorts with the CIRT cohort, significantly higher OS was found for CIRT compared with margin-positive surgery without adjuvant radiotherapy (CIRT: median OS, 64.7 [95% CI, 57.8-69.7] months; margin-positive surgery without adjuvant radiotherapy: median OS, 60.6 [95% CI, 44.2-69.7] months, P = .03) and primary radiotherapy alone (CIRT: median OS, 64.9 [95% CI 57.0-70.5] months; primary radiotherapy alone: 31.8 [95% CI, 27.9-40.6] months; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that CIRT can be used as treatment for older patients with high performance status and sacral chordoma in whom surgery is not preferred. CIRT might provide additional benefit for patients who undergo margin-positive resection or who are candidates for primary photon radiotherapy.

Identified Enrollment Challenges of Adolescent and Young Adult Patients on the Nonchemotherapy Arm of Children's Oncology Group Study ARST1321

ARST1321, a trial of patients with advanced soft tissue sarcoma, was the first National Clinical Trials Network study codeveloped by pediatric and adult consortia with two treatment cohorts. We report on the findings of a survey to identify barriers to enrolling adolescent and young adult patients (15-39 years) onto the nonchemotherapy arm. The survey response rate was 31% with a 70% completion rate. Common identified reasons for low accrual in order of decreasing frequency included insufficient funding, lack of study awareness or interest, competing trials, toxicity concerns, philosophical differences in the therapy backbone, and regulatory and infrastructure barriers. Clinical Trials.gov ID: NCT02180867.

Outcome of Soft-tissue Reconstruction in the Setting of Combined Preoperative and Intraoperative Radiotherapy for Extremity Soft-tissue Sarcomas

BACKGROUND/AIM

Reconstruction for soft-tissue sarcomas is complex and often uses soft-tissue flaps. To preserve critical structures, intraoperative radiotherapy (IORT) can be used to boost the total dose to these critical structures and close margins; however, there are limited data on the outcome of soft-tissue reconstruction in patients treated with IORT.

PATIENTS AND METHODS

Twenty patients received IORT with soft-tissue flap coverage. There were 14 tumors of the lower extremities and six of the upper, including seven free-flaps and 13 pedicle flaps. Mean preoperative and IORT doses were 49.4 Gy and 10.4 Gy, respectively, with a mean total dose of 59.8 Gy.

RESULTS

Seven (35%) patients had a complication, most commonly an infection (n=4, 27%). Total flap loss occurred in one treated with pedicle flap. Four (20%) patients suffered a radiation-associated fracture. At the final follow-up, the mean Musculoskeletal Tumor Society Score was 75±11%.

CONCLUSION

Complications and postoperative fractures were common with IORT, however, there were no cases requiring amputation.

Endonasal surgery in the coronavirus era - Birmingham experience

BACKGROUND

The World Health Organization declared coronavirus disease 2019 a pandemic on 11th March 2020. There is concern regarding performing endonasal surgical procedures because of a high viral load in the nasopharynx. This paper describes our experience in conducting emergency and urgent endonasal operations during the peak of the coronavirus disease 2019 pandemic in the UK.

OBJECTIVES

To show the outcome of endonasal surgery during the peak of the coronavirus disease 2019 pandemic and to assess the post-operative rate of nosocomial coronavirus disease 2019 infection.

METHODS

A retrospective cohort study was conducted of all patients who underwent high priority endoscopic nasal surgery or anterior skull base surgery between 23rd March and 15th June 2020 at University Hospitals Birmingham NHS Trust.

RESULTS

Twenty-four patients underwent endonasal surgery during the study period, 12 were males and 12 were females. There was no coronavirus-related morbidity in any patient.

CONCLUSION

This observational study found that it is possible to safely undertake urgent endonasal surgery; the nosocomial risk of coronavirus disease 2019 can be mitigated with appropriate peri-operative precautions.

Patient-reported functional outcomes in a cohort of hand and foot sarcoma survivors treated with limb sparing surgery and radiation therapy

BACKGROUND AND OBJECTIVES

Describe patient-reported functional outcomes for hand and foot sarcoma survivors treated with limb-sparing surgery and radiation therapy (LSS + RT).

METHODS

Fifty-four patients with hand/wrist and foot/ankle sarcomas treated with LSS + RT from 1991 to 2015 were identified. Survivors ≥18 years old without subsequent amputation completed self-assessed functional surveys: Toronto upper extremity salvage score (TESS-UE) and Michigan hand outcomes (MHQ) surveys for hand; TESS lower extremity (TESS-LE) and Foot and Ankle Outcomes (FAOS) surveys for foot. Scoring scales: 0-100, MHQ and TESS; -26 to 56 and 25-59, FAOS core and shoe comfort, respectively. Higher scores denote superior function.

RESULTS

Five-year local tumor control was 88%. Fourteen of 24 hand (58%) and 14/18 foot (78%) survivors completed surveys. Mean TESS-UE and MHQ scores were 89.4 and 72.8, respectively. Mean TESS-LE, core FAOS, and shoe comfort scores were 92.4, 46.19, and 53.1, respectively. No factors correlated with outcomes. TESS-UE and MHQ scores strongly correlated (r = .87). TESS-LE and FAOS scores were associated with a poor correlation (r = .02 and r = .69).

CONCLUSIONS

The largest patient-reported functional outcomes analysis for hand and foot sarcoma survivors treated with LSS + RT demonstrates excellent local tumor control and acceptable functional outcomes. Further exploration of optimal functional assessment tools is needed given the potential scope differences.

Enrollment barriers of adolescents and young adults (AYA) on the non-chemotherapy arm of ARST1321

e19214

Background: ARST1321(PAZNTIS): A Phase II/III Randomized Trial of Preoperative Chemoradiation or Preoperative Radiation Plus or Minus Pazopanib (NCT02180867) was the first National Clinical Trials Network (NCTN) study co-developed by pediatric (COG) and adult (NRG Oncology) consortia anticipating enrollment of adolescent and young adult (AYA) cancer patients. ARST1321 had two treatment cohorts, enrolling patients ≥ 2 years of age to either chemotherapy (C) (chemoradiation ± pazopanib) or non-chemotherapy (NC) (radiation ± pazopanib) arms. It was anticipated adults would contribute the majority of enrollments on the NC arm based on prior enrollment patterns. While the C arm accrued as anticipated (with high enrollment of adults and children), the NC arm had low enrollment leading to premature closure. We report on AYA accrual (defined as 15-39 years) to the NC arm and a survey aiming to identify barriers to enrolling AYA patients onto ARST1321. Methods: Our survey was emailed to 161 adult, surgical, and radiation oncologists at large sarcoma centers. A link was sent to an online questionnaire via SurveyMonkey Inc. and responses were reviewed on their platform. Results: 33 patients enrolled on the ARST1321 NC arm, of which 24% were AYA. 25% of AYA enrollments were from non-COG adult cooperative groups. This trial arm was closed in October 2017 after 3.25 years of accrual below anticipated rates. The survey response rate was 31% with a 70% completion rate. Almost half of respondents were medical oncologists with most seeing 50-200 new sarcoma cases/year at an academic institution and 30% in a pediatric environment (divided equally between radiation and surgical oncologists). 70% of respondents have a joint collaboration with their pediatric oncology team with 23% having a joint clinic. 70% of respondents’ sites opened ARST1321 and anticipated 1-5 patients would be eligible for the NC cohort. However, 42% of respondents’ sites had zero patients enrolled on that arm. The most common reasons for not opening the study and/or not enrolling patients on the NC arm included: lack of interest, disagreement with the therapy, lack of a site investigator, premature study closure, patient/family decision, competing trials, insufficient reimbursement, and regulatory delays. Conclusions: Our survey highlights multiple barriers to enrollment of AYA onto cross-NCTN consortia clinical trials spanning the age spectrum. The information obtained will help inform investigators aiming to effectively design, enroll, and conduct similar trial efforts for AYA in the future.

Prevalence of ticks (Acari: Ixodidae) and Theileria annulata infection of cattle in Gezira State, Sudan

This study was conducted in Gezira State, central Sudan during January, May and August 2014 to determine species of ticks infesting cattle and prevalence of Theileria annulata infection and antibodies. A total of 200 head of cattle were sampled for ticks, blood smears, lymph node biopsy smears and sera from five study areas. Zebu (Butana and Kenana) and cross-bred (Zebu X Friesian) cattle of both sexes were sampled. Cattle age groups were younger than one year, one year to younger than four years and four years and older. Coat colour of cattle was recorded. The results revealed that cattle were infested with Rhipicephalus evertsi evertsi (n = 562, 51.6%), Hyalomma anatolicum (n = 289, 26.5%), H. rufipes (n = 70, 6.4%), R. sanguineus sanguineus (n = 59, 5.4%), R. decoloratus (n = 39, 3.6%), Amblyomma lepidum (n = 35, 3.2%), H. impeltatum (n = 26, 2.4%) and H. dromedarii (n = 9, 0.8%). Out of 200 blood and biopsy smears, 33 (16.5%) showed piroplasms for Theileria spp., while 29 (14.5%) were positive for Theileria spp. schizonts. Seropositivity for T. annulata using indirect fluorescent antibody (IFA) test was 94 (47%). It is concluded that there are three genera of hard ticks and eight species in Gezira State and tropical theileriosis is endemic in the state. These findings are the first records in Gezira State, Central Sudan and it is highly recommended to consider the endemicity of tropical theileriosis particularly in cattle upgrading programmes.

Radiotherapy Does Not Impact Long-term Function Following Resection of Soft-tissue Sarcomas of the Hand

BACKGROUND/AIM

Radiotherapy for soft tissue sarcomas (STS) of the hand is thought to be associated with poor function. The aim of this study was to compare the long-term functional outcome in patients with and without radiotherapy.

PATIENTS AND METHODS

At long-term follow-up (mean 10±5 years), 33 (13 males, 20 female) patients, were alive for review. The mean patient age at surgery was 33±17 years and 13 (39%) patients received radiotherapy (mean dose 55±6 Gy).

RESULTS

Postoperatively, the mean QuickDASH and MSTS93 were 7±8 and 92±8%, respectively. Comparing patients with and without radiotherapy, there was no difference (p>0.05) between the mean QuickDASH (5±5 vs. 8±9) or MSTS93 (93±9% vs. 91±8%). Surgical complication occurred more commonly in patients with radiotherapy (46% vs. 15%, p=0.10).

CONCLUSION

The use of radiotherapy was associated with a higher rate of complications, however, was not associated with a worse long-term functional outcome in patients with hand STS.

Extremity Soft Tissue Sarcoma: Role of Local Control

OPINION STATEMENT

For localized extremity soft tissue sarcoma (eSTS), treatment is individualized and each patient needs to be evaluated by a multidisciplinary team at a referral sarcoma center specialized in the care of sarcoma. For a majority of patients, treatment for eSTS involves limb-salvage surgery, with or without the addition of radiation therapy. Surgery should only be performed by surgeons specifically fellowship trained in the resection of eSTS. Surgery alone may be considered for small, low-grade, and superficial tumors as long a wide (≥ 2 cm) margin can be achieved. In cases where a less than wide negative margin can be achieved, radiation therapy should be utilized to facilitate a planned close margin resection to preserve critical structures (such as nerves, blood vessels, and bone) without a significant impact on oncologic outcomes. Soft tissue sarcomas are rare, and as such patients often present following an inadvertent excision. In these situations, we recommend preoperative radiation and wide tumor bed re-excision, as rates of residual tumor can be high in this scenario. While there is large amount of evidence to support the use of radiotherapy to enhance local tumor control, the evidence to support the use of chemotherapy to enhance local tumor control is lacking, and as such cannot be recommended for all patients.

Protons vs Photons for Brain and Skull Base Tumors

The physical characteristics of proton therapy result in steeper dose gradients and superior dose conformality compared to photon therapy. These properties render proton therapy ideal for skull base tumors requiring dose escalation for optimal tumor control, and may also be beneficial for brain tumors as a means of mitigating radiation-related adverse effects. This review summarizes the literature regarding the role of proton therapy compared to photon therapy in the treatment of adult brain and skull base tumors.

Clinical efficacy and safety of a highly conformal, supine, hybrid forward and inverse planned intensity modulated radiation therapy technique for craniospinal irradiation

PURPOSE

To demonstrate the clinical efficacy and safety of a highly conformal, supine, hybrid forward and inverse planned intensity modulated radiation therapy (IMRT) technique for photon craniospinal irradiation (CSI).

METHODS

Patients who received supine, hybrid IMRT CSI from 2009 to 2014 were included in this retrospective review. Clinical target volume (CTV) was defined as intracranial contents and thecal sac, including nerve roots. Dose was prescribed such that >99% of CTV received >99% of prescription and >95% of the planning target volume received >95% of prescription, with no attempt to include vertebral bodies. Lateral fields were utilized at the cranium and upper cervical spine. Spine fields were either single posterior or 2-3 obliques. Plans were generated with a hybrid of forward and inverse planned IMRT. Inferior borders of the cranium fields and superior border of the lower spine field were designed with 6-15 cm long, gradual dose gradients by sequential closing of multileaf collimator leaves using forward planned multiple static segment IMRT delivery. The sliding window upper spine IMRT field was created by the inverse planning system to match gradients of the brain and lower spine fields. The lower spine field gradient was similarly completed.

RESULTS

The cohort consisted of 34 patients. Median CSI dose was 36 Gy (range: 18-39.6 Gy). With a median follow up of 59.4 months, there were no isolated recurrences or spinal myelopathies at CTV margins or field gradients. Eleven patients had recurrence, all of which were intracranial.

CONCLUSIONS

Our hybrid forward and inverse planned IMRT supine CSI technique did not result in any isolated recurrences or myelopathies at CTV margins or field gradients. This suggests our target volumes and blended gradients are appropriate for highly conformal three-dimensional planning.

Pelvis Ewing sarcoma: Local control and survival in the modern era

PURPOSE

Local control for Ewing sarcoma (ES) has improved in modern studies. However, it is unclear if these gains have also been achieved for pelvis tumors. The purpose of this study is to evaluate local control and survival in pelvis ES patients treated in the modern era.

METHODS

All pelvis ES patients diagnosed from 1990 to 2012 and seen at Mayo Clinic were identified. Factors relevant to survival and local control were analyzed.

RESULTS

The cohort consisted of 48 patients. Fifty-two percent had metastatic disease at diagnosis. The 5-year overall survival and event-free survival was 73% and 65%, respectively, for localized disease. The 5-year cumulative incidence of local recurrence was 19%, with a 26% incidence for radiation, 13% for surgery, and 0% for surgery + radiation (P = 0.54). All local failures occurred in-field. Sacral involvement by tumor trended toward a higher incidence of local recurrence (hazard ratio 3.06, P = 0.09). Patients treated with definitive radiation doses ≥5,600 cGy had a lower incidence of local recurrence (17% vs. 28%, P = 0.61).

CONCLUSIONS

Our study demonstrates excellent survival for localized tumors in the modern era. Anatomical localization within the pelvis likely correlates with outcomes. Local control remains problematic, especially for patients treated with definitive radiation. Though statistically not significant, surgery + radiation and definitive radiation dose ≥5,600 cGy were associated with the lowest incidence of local failure, suggesting treatment intensification may improve local control for pelvis ES.

Identification of Patients With Localized Ewing Sarcoma at Higher Risk for Local Failure: A Report From the Children's Oncology Group

PURPOSE

To identify clinical and treatment variables associated with a higher risk of local failure in Ewing sarcoma patients treated on recent Children's Oncology Group protocols.

METHODS AND MATERIALS

Data for 956 patients treated with ifosfamide and etoposide-based chemotherapy on INT-0091, INT-0154, and AEWS0031 were analyzed. Local treatment modalities were defined as surgery, definitive radiation therapy (RT), or surgery plus radiation (S+RT). Five-year cumulative incidence of local failure was determined.

RESULTS

The local failure rate for the entire cohort was 7.3%, with a 3.9% rate for surgery, 15.3% for RT (P<.01), and 6.6% for S+RT (P=.12). The local failure incidence was 5.4% for extremity tumors, 13.2% for pelvis tumors (P<.01), 5.3% for axial non-spine tumors (P=.90), 9.1% for extraskeletal tumors (P=.08), and 3.6% for spine tumors (P=.49). The incidence of local failure was 14.8% for extremity tumors and 22.4% for pelvis tumors treated with RT, compared with 3.7% for extremity tumors and 3.9% for pelvis tumors treated with surgery (P≤.01). There was no difference in local failure incidence by local treatment modality for axial non-spine, spine, and extraskeletal tumors. The local failure incidence was 11.9% in patients aged ≥18 years versus 6.7% in patients aged <18 years (P=.02). Age ≥18 years (hazard ratio 1.9, P=.04) and treatment with RT (hazard ratio 2.40, P<.01) remained independent prognostic factors for higher local failure incidence on multivariate analysis. Tumor size (</≥ 8 cm) was available in 40% of patients and did not correlate with local failure incidence.

CONCLUSIONS

Local tumor control is excellent and similar between surgery and RT for axial non-spine, spine, and extraskeletal tumors. Age ≥18 years and use of RT, primarily for pelvis and extremity tumors, are associated with the highest risk of local failure. Further efforts should focus on improving outcomes for these patients.

Unabsorbed dura patch removed eight years after pituitary surgery

The Codman ETHISORB Dura Patch is a synthetic, absorbable material whose absorption is complete within approximately 90 days. We report the first case of an unabsorbed Codman Dura patch, in which a patient was presented with nasal obstruction and epistaxis 8 years after pituitary surgery for Cushing's disease.

Patient-Reported Functional and Quality of Life Outcomes in a Large Cohort of Long-Term Survivors of Ewing Sarcoma

BACKGROUND

Little data exist regarding long-term functional and quality of life (QOL) outcomes for survivors of Ewing sarcoma (ES). Specifically, there are few reports assessing the impact of patient characteristics and local therapy modalities on patient-reported outcomes (PRO).

PROCEDURE

Long-term survivors of ES treated between 1977 and 2009 completed self-assessed functional and QOL surveys, using the Toronto Extremity Salvage Score (TESS) and PEDSQL 4.0 generic core instruments, respectively. Statistical analyses were performed to correlate these outcomes to clinical presentations and treatment regimens.

RESULTS

Subjects (n = 74) with a mean duration from diagnosis of 17.8 years completed the survey. Mean TESS and PEDSQL total scores for the entire cohort were 93.0 ± 10.3 and 81.6 ± 18.0, respectively. No significant differences were appreciated between adult and pediatric patients, although increasing age was associated with lower functional scores (P = 0.04). Mean PEDSQL total scores were significantly lower for female patients (74.6 ± 19.7) compared to males (85.7 ± 15.7) (P = 0.01). Mild to moderate disability was reported by 32% of respondents and was associated with lower TESS and PEDSQL scores. Local control modality did not significantly affect functional and QOL scores. Patients with pelvic tumors had significantly lower TESS scores compared to those with nonpelvic tumors (P = 0.04), especially amongst patients treated with both surgery and radiation.

CONCLUSIONS

Although many survivors of ES report excellent functional and QOL outcomes, a significant number report long-term disability and impairments. Older patients, females, and those with pelvic primary tumors appear at the greatest risk for long-term decrements and may benefit from early therapeutic interventions.

Three-Dimensional Hand-to-Gland Combat: The Future of Endoscopic Surgery?

Objective To compare two dimensional (2D), three-dimensional (3D) non-high-definition (HD), and 3D HD endoscopic surgical techniques. Methods We describe our initial operative experience with a novel 3D HD endoscopic endonasal approach involving a pituitary adenoma resection, provide a case series, and review the current literature. This is the first case in Europe using the new 3D HD endoscope. Results Although research evidence remains limited, there are no significant negative perioperative or postoperative outcomes when compared with 2D endoscopic techniques. In our experience the narrow operating corridors of endoscopic surgery cannot be addressed with 3D endoscopic techniques. The new 3D HD endoscope creates imaging quality similar to conventional 2D HD systems. Conclusion Three-dimensional endoscopic endonasal techniques provide an exciting new avenue, effectively addressing potential depth perception difficulties with current 2D systems.

Pediatric Metastatic Odontogenic Ghost Cell Carcinoma: A Multimodal Treatment Approach

Odontogenic ghost cell carcinoma (OGCC) is a rare and aggressive tumor wherein optimal treatment remains uncertain. We report the first pediatric metastatic OGCC case treated with multimodal therapy: surgery, adjuvant chemoradiation, and adjuvant immunotherapy. Adjuvant therapy was utilized due to locally advanced disease with pathologic features indicative of high recurrence risk. This multimodal approach was modeled after management of primary head and neck cancer, where adjuvant chemoradiation and immunotherapy are associated with improved outcomes. Our patient is alive and disease free at 14 months indicating a potentially positive role for multimodal therapy in the management of OGCC.

Spontaneous maxillary sinus rupture in the absence of pre-existing sinus disease: case report

INTRODUCTION

Spontaneous fracture of the maxillary sinus is usually associated with enophthalmos and pre-existing sinus disease.

CASE REPORT

We present a case of spontaneous maxillary sinus fracture without enophthalmos and with no preceding history of trauma or evidence of sinusitis.

DISCUSSION

The closest condition to that presented is silent sinus syndrome. The differences between our case and this syndrome are reviewed. There are no previously reported cases of lateral wall maxillary fracture and associated facial surgical emphysema following nose-blowing.

General practitioners’ referral pattern for children with acute facial paralysis

Introduction: The relative incidence of paediatric Bell’s palsy is two to four times less than the condition in adults. The number encountered in our otolaryngology department falls short of the above prediction. This could either reflect the general practitioners' (GPs) patterns of referral or a lower incidence in our locality.

Methods: Postal questionnaires were sent to our local GPs to determine their referral practice when managing children presenting with acute facial paralysis.

Results: Of 233 questionnaires, 172 (74 per cent) were returned and analysed. Fifty-four per cent of GPs referred their patients to the local paediatric services, 22 per cent to an otolaryngologist, and the remaining 24 per cent of GPs were confident in diagnosing and managing Bell's palsy in children themselves.

Discussion and Conclusion: Of the GPs surveyed 78 per cent did not refer children presenting with acute facial paralysis to an otolaryngologist. We suggest minimum investigations for acute facial paralysis in children before diagnosing Bell's palsy and stipulate otolaryngology referral for all.

Colloid cysts of the third ventricle in identical twins

A young man presented to our unit with a colloid cyst of the third ventricle. Following successful surgical treatment his parents expressed concern over the possibility of his identical twin brother having a similar cyst. After finding one other case of colloid cysts in identical twins in the world literature we arranged a magnetic resonance scan of the asymptomatic twin. We were sceptical, but much to our surprise the scan also showed a colloid cyst in the third ventricle. Familial colloid cysts of the third ventricle have been reported only rarely. This is the second account of third ventricular colloid cysts in identical twins reported in the world literature. We present case reports of the twins, discuss the world literature on familial colloid cysts and also the genetic implications.

An exploratory study of buprenorphine use in Bangladesh: a note

A pilot study was carried out in Bangladesh during August and September, 1995, using a "snowball" technique with 30 male multiple drug users in order to investigate buprenorphine use, characteristics of the users, their reasons for its use and the drug's effects.

A natural response to drug misuse problems: a review of drug-user treatment services of Bangladesh

This paper reviews and describes the natural processes through which the people of a Third World country, Bangladesh, have been trying to provide treatment to drug misusers. As the demand for medical help increases, different organizations develop to cater to the needs. Bangladesh has followed the age-old ashram model and the contemporary medical hospital model to provide services to its addicts. In reality the drug misuse treatment providers are still evolving through different learning stages about the biopsychosocial manifestations of addiction. According to the authors, the stages of learning can be divided into three phases: 1) the early period of confusion and enthusiasm, 2) the period of truism, and 3) the period of pragmatism. The people who have gained experience in running treatment centers in the last decade need to form alliances to share their experiences in order to develop rational models for drug treatment programs in Bangladesh. It is also important that they develop methods to monitor providers' activities and to protect clients' safety and interests.