Recommendations for hypofractionated whole-breast irradiation.

Expenditures and Use of Hypofractionated Radiation Therapy Treating Breast Cancer Among Medicare Advantage Enrollees, 2009 to 2017

Esotropia and Exotropia Preferred Practice Pattern®

Objective To observe the long-term effect, adverse reaction and cosmetic outcome of early-stage breast cancer with hypofractionated whole-breast irradiation (HF-WBI) after breast-conserving surgery. Methods A total of 206 patients with stage 0-Ⅱ breast cancer after breast-conserving surgery were included in Shandong Cancer Hospital Affiliated to Shandong University from May 2014 to August 2017. According to radiotherapy fraction, patients were divided into HF-WBI group and conventional whole-breast irradiation (CF-WBI) group. In HF-WBI group, 116 patients received whole-breast radiation to 42.56 Gy in 16 fractions followed by tumor bed boost of 9 Gy in 3 fractions or 10 Gy in 5 fractions. In CF-WBI group, 90 patients received whole breast radiation to 50 Gy in 25 fractions followed by tumor bed boost of 10 Gy in 5 fractions. The 2-year local recurrence rate, 2-year mortality rate, acute adverse reaction, late adverse reaction and cosmetic outcome of the two groups were analyzed. Results The 2-year local recurrence rates of HF-WBI group and CF-WBI group were 0.86% (1/116) and 2.22% (2/90) respectively, and there was no significant difference between the two groups (χ2=0.049, P=0.824). The 2-year mortality rates of the two groups were 0.86% (1/116) and 0 (0/90) respectively, and there was no significant difference (P>0.999). There were 108 cases (93.1%) in HF-WBI group and 84 cases (93.3%) in CF-WBI group with grade 0-1 acute dermatitis, and 8 cases (6.9%) and 6 cases (6.7%) with grade 2-3 respectively, with no statistically significant difference (χ2=0.004, P=0.948). There were 97 cases (83.6%) in HF-WBI group and 79 cases (87.8%) in CF-WBI group with grade 0-1 bone marrow suppression, and 19 cases (16.4%) and 11 cases (12.2%) with grade 2-4 respectively, with no statistically significant difference (χ2=0.704, P=0.401). In the two groups, there were 1 case (0.9%) and 3 cases (3.3%) with grade 1-2 radiation pneumonitis, and 115 cases (99.1%) and 87 cases (96.7%) with no radiation pneumonitis respectively, and the difference was not statistically significant (χ2=1.626, P=0.202). There was 1 case (0.9%, 1.1%) with grade 1 breast edema in each group, and 115 cases (99.1%) and 89 cases (98.9%) did not occur breast edema, with no statistically significant difference (χ2=0.033, P=0.857). In the late adverse reactions, there were 5 cases (4.3%) and 3 cases (3.3%) with skin pigmentation in HF-WBI group and CF-WBI group respectively. There were 2 cases (1.7%, 2.2%) with grade 1 subcutaneous tissue fibrosis in each group, and there were 1 case (0.8%) and 2 cases (2.2%) with grade 1 pulmonary fibrosis respectively. The differences between the two groups were not statistically significant (χ2=0.000, P>0.999; χ2=0.000, P>0.999; χ2=0.049, P=0.824). The 6-month, 1-year and 2-year cosmetic outcome good rates in HF-WBI and CF-WBI group were 96.5% (111/115) and 93.3% (84/90), 92.1% (105/114) and 90.0% (81/90), 91.4% (53/58) and 87.2% (41/47) respectively. The differences between the two groups were not statistically significant (χ2=0.526, P=0.468; χ2=0.277, P=0.599; χ2=0.476, P=0.490). The whole course of radiotherapy time in HF-WBI group was 25 days or 29 days, which was significantly shorter than the 40 days of CF-WBI group. Conclusion HF-WBI after breast-conserving surgery has the similar long-term effect, acute and late adverse reaction and cosmetic outcome compared with CF-WBI, and the treatment time is significantly shorter. It can be further promoted as the optimal adjuvant radiotherapy for early-stage breast cancer after breast-conserving surgery. Key words: Breast neoplasms; Radiotherapy; Treatment outcome

Background: Women with large breast tumors are often treated with mastectomy as their definitive operation. However, women with large breasts can have a significant resection and still achieve an excellent aesthetic outcome if the partial mastectomy is combined with a reduction mammoplasty. It is not clear if the limitation for breast conservation should be made based on tumor size, or on the basis of the volume of tissue that needs to be resected relative to the total volume of breast tissue. Our study aims to assess the oncologic safety and cosmetic outcome of large partial mastectomies in large breasted women combined with reduction mammoplasty.Materials and Methods: All patients undergoing partial mastectomy and reduction mammoplasty performed at the University of California San Francisco were included. Medical records were reviewed for demographics, breast cancer data, oncologic and reconstructive operations, postoperative recurrences, complications, and need for additional operations.Results: Sixty-five patients undergoing partial mastectomy and reduction mammoplasty reconstruction were identified. Average tumor size was 2.8 cm (range 0.6 cm to 8.9 cm). The stage distribution for 63 patients was stage 0 (n=11), I (n=15), II (n=24), III (n=10), and IV (n=3), and 2 patients had Phylloides tumor. Twenty-five patients had neoadjuvant therapy, followed by breast reduction as their primary resection once chemotherapy was completed. Twenty patients (30.8%) required re-excision, four of whom required multiple re-excisions. Fifty nine patients (90.8%) were successfully treated with our approach, while 6 patients (9.2%) required completion mastectomy for their definitive resection, based on margin status after initial resection. There were a total of two recurrences, one in a patient who had a local DCIS recurrence after initial presentation with stage 0 disease and one in a patient who presented with metastatic disease. The patient with stage 0 disease and subsequent recurrence did not have radiation; the other patient presented initially with synchronous metastatic disease, had a poor response to chemotherapy, and her local recurrence occurred simultaneously with progression of distant disease. Of the patients with stage 0-III disease, the recurrence rate was 1.6% with a mean follow-up of 13 months. Eleven patients (15.9%) developed postoperative complications, including fat necrosis (n=1), hematoma (n=1), cellulitis (n=2), seroma (n=3), and wound healing complications (n=4). Despite complications and radiation therapy, all patients were exceptionally pleased with their reconstruction.Conclusion: Partial mastectomy with reduction mammoplasty breast reconstruction is a viable option that combines a safe oncologic procedure with immediate breast reconstruction. While further follow-up is needed, it is a viable alternative to mastectomy, enabling breast conservation and correction of significant breast redundancy and ptosis, which can impair the efficacy of radiation therapy. Prospective data collection should continue for these cases to establish the long term outcomes of large-breasted patients undergoing partial mastectomy and reduction mammoplasty. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4125.

Objective To evaluate the clinical efficacy and safety of simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) to the tumor center in the treatment of bulky cervical cancer with massive bleeding in the first course radiotherapy. Methods Twenty-one cases with bulky cervical cancer complicated with massive vaginal bleeding were enrolled. At the first three times of external irradiation, a high dose radiotherapy (15 Gy/3 fractions) was delivered to the tumor center (the region retracted 2 cm from the periphery of cervical mass), followed by conventional irradiation (2 Gy/fraction) in the posterior course. Conventional dose irradiation (46 Gy/23 fractions) was given to the tumor periphery and pelvic lymphatic drainage area throughout the whole course. Concurrent chemotherapy by cisplatin at a dose of 25 mg/m2 was delivered weekly. After the external irradiation, intracavitary radiotherapy was given (20 Gy/4 fractions). Results Within 24 h after the first course radiotherapy, the volume of vaginal bleeding was significantly decreased by 50% and the bleeding was almost stopped within one week. The hemostasis rate was 100%. Conclusions SIB-IMRT into the center of bulky cervical cancer is an efficacious treatment of massive vaginal bleeding. Key words: Cervical neoplasm/simultaneous integrated boost intensity-modulated radiotherapy; Massive bleeding; Hemostasis

Background:Breast reconstruction after salvage mastectomy (SM) for recurrent cancer represents a challenge in preradiated patients due to the increased complication rate. Latissimus dorsi myocutaneous flap (LDMF) represents a good reconstructive option due to its versatility, safety, and adaptability.Methods:Fifty-nine patients treated in the Breast Surgery Unit at the University Hospital of Parma (Italy) between January 2010 and December 2017 for ipsilateral breast recurrent cancer, previously treated by partial mastectomy plus whole-breast radiation therapy, were analyzed. They underwent SM and immediate reconstruction with implant-assisted pedicled LDMF. We registered local treatment, oncologic characteristics, complications, capsular contracture rate, DASH test, and BREAST-Q scores.Results:Mean implant volume was 403 g (range 135–650 g). Contralateral operations were 16/59 (27.1%). We obtained complete postoperative pain control in most cases with paracetamol. Medium hospital stay was 2.8 days. We registered 3.4% major complications and 6.8% minor ones. Mean follow-up was 26.65 months (range 3–91.9 months). DASH questionnaire evidenced no disability for 71.19% of patients and minimum disability for 28.81% of them. BREAST-Q Aesthetic Questionnaire obtained 92.72%. No patient developed Baker III or IV capsular contracture.Conclusions:LDMF with implant is a reliable and safe procedure for 1-step breast reconstruction after SM for recurrent cancer in radiated breast. It entails a low rate of major complications, achieving stable and pleasant results without significant upper limb functional impairment, also for elderly women and larger breasts. Thus, a definite role is yet predictable for this flap in the setting of SM in all cases not suitable for free-flap reconstruction.

The aim of this scoping review was to identify clinical guidance for maintaining oral hygiene in patients undergoing chemotherapy, radiation therapy, or both. Electronic searches were conducted in PubMed, Embase, Cochrane Library, and Google Scholar for articles published between January 2000 and May 2020. Systematic reviews, meta-analyses, clinical trials, case series, and expert consensus reports were considered eligible for inclusion. The SIGN Guideline system was used to evaluate the level evidence and the grade of recommendations. A total of 53 studies met the eligibility criteria. The results showed the presence of recommendation for oral care in three domains: management of oral mucositis, prevention and control of radiation caries, and management of xerostomia. However, most of the included studies had low levels of evidence. The review provides recommendations for healthcare professionals caring for patients undergoing chemotherapy, radiation therapy, or both, but a standard oral care protocol could not be established owing to a paucity of evidence-based data. Accepted for publication: February 20, 2023 Published online: February, 2022

Objective This non-randomized prospective phase II study was designed to investigate the safety and feasibility of adjuvant intensity-modulated radiotherapy or three-dimensional conformal radiotherapy (IMRT/3DCRT) after radical surgery for pT2-3 N0M0 thoracic esophageal squamous cell carcinoma (TESCC) . Methods Ninety-six patients were enrolled from 2004 to 2011. The prescribed dose was 50-60 Gy in 1.8-2.0 Gy per fraction (5 days per week) to 95%of the planning target volume (PTV) , encompassing the tumor bed and lymphatic drainage regions at high risk according to the primary tumor location. The survival rate was calculated by Kaplan-Meier method. Results The average PTV coverage of the prescribed dose was (94.9±0.7) %. The median bilateral lung V20 was 23.6% (9.8%-29.7%) ; the median stomach V50 was 9.4% (0-39.2%) ; the median heart V30 and V40 were 33.3% (0-67.6%) and 17.1% (0-42.0%) , respectively ; the median maximal dose to the spinal cord was 40.4 Gy (32.9-45.5Gy). The number of samples at 5 years was 35. The 5-year overall survival rate and disease-free survival rate were 74%and 71%, respectively. Grade 3 and 4-5 toxicities occurred in 25 (26%) and 0 patients, respectively. Recurrence and metastasis were seen in 22 (23%) patients, of whom 18 (19%) and 11 (12%) had locoregional recurrence and distant metastasis, respectively. Conclusions Adjuvant IMRT/3DCRT for pT2-3 N0 M0 TESCC is tolerable and clinically feasible, and provides excellent local control and favorable survival. Further confirmation in a randomized trial is merited. Key words: Esophageal neoplasms/radiotherapy; Radiotherapy, intensity-modulated; Radiotherapy, three-dimensional conformal; Dosimetry; Prognosis

Screening for Lung Cancer: CHEST Guideline and Expert Panel Report

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

BackgroundThe rising popularity of electronic cigarettes (e-cigarettes), the nicotine product that is most used by adolescents since 2014, has reversed decades of progress in declining youth tobacco use. E-cigarette use in adolescents is associated with future smoking, and evidence is mounting of an increased association with nicotine dependence. Therapies used to treat nicotine dependence in adults include pharmacotherapy and behavioral interventions. Pediatric guidelines recommend routine screening for any tobacco product use beginning at age 10 years. The goal of this guideline was to develop an evidence-based clinical practice guideline for the treatment of nicotine use in adolescents.MethodsWe summarized evidence addressing five PICO (patients, intervention, comparator, and outcome) questions, which were formulated by a multidisciplinary panel of experts and methodologists using the evidence-to-decision framework. The Grading of Recommendations, Assessment, Development, and Evaluation (or, GRADE) approach was used to evaluate the certainty in evidence and generate actionable recommendations, which were voted on by the panel.ResultsThe panel members considered the strength of the evidence as well as the potential benefits of the treatment modality from a clinical standpoint. The overall quality of the evidence was weak. Recommendations for or against the treatment modality for nicotine use were developed.ConclusionsThis expert panel provides evidence-based recommendations for treating nicotine use in adolescents 10 to 18 years of age.

Objective To explore the incidence and related predictive factors for acute symptomatic esophagitis in patients with locally advanced non-small cell lung cancer (NSCLC) treated with intensity-modulated radiation therapy (IMRT). Methods Data were collected retrospectively from 256 patients with inoperable or unresectable stage Ⅲ NSCLC treated in our hospital between January 2007 and December 2011.The radiotherapy target volume included primary lung cancer and lymphatic drainage area involved, with a median dose of 60 Gy in 30 fractions (50-70 Gy). Of all the patients, 109 patients (42.6%) received concurrent chemotherapy. Grade ≥2 acute esophagitis (AE)(symptomatic esophagitis) which occurred during radiotherapy and within 3 months after completion of radiotherapy served as the outcome event. National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0(NCI-CTCAE3.0) was used to evaluate the grade of AE.The logistic regression model was used to analyze the predictive factors. Results A total of 174 patients (68%) had treatment-related grade ≥2 AE; 154 patients (60.2%) had grade 2 AE and 20 patients (7.8%) had grade 3 AE.The median dose when grade ≥2 AE occurred was 30 Gy (11-68 Gy). For grade ≥2 AE, multivariate analysis showed that esophageal V5-V60, mean dose, and age were independent predictive factors (P=0.021, 0, 0.010). For grade ≥3 AE, multivariate analysis showed that esophageal V50-V60, concurrent chemotherapy, and body mass index (BMI) were independent predictive factors (P=0.010, 0.003, 0.019). Old age and higher BMI were the protective factors for grade ≥2 and≥3 AE, respectively. Conclusions For patients with locally advanced NSCLC treated with IMRT, esophageal V50–V60 and concurrent chemotherapy are predictive factors for grade ≥3 AE, and esophageal V50 has a high predictive value for both grade ≥2 and ≥3 AE. Key words: Cacinoma, non-small cell lung/intensity modulated radiotherapy; Cacinoma, non-small cell lung/chemotherapy; Acute symptomatic esophagitis

Concurrent Cyclophosphamide, Methotrexate, and 5-Fluorouracil Chemotherapy and Radiotherapy for Early Breast Carcinoma

Breast conserving therapy remains one of the most important advances in cancer management in the past century, with multiple trials demonstrating its equivalence to mastectomy with respect to long term cancer outcomes. Unfortunately, studies have documented that adjuvant radiation therapy, a critical component of breast conserving therapy, remains under utilized. Data suggest that treatment duration (5–6.5 weeks) can frequently be attributed to this finding. In light of this and secondary to the increasing costs associated with breast cancer radiation therapy, shortened courses of radiation therapy have been explored including both hypofractionated whole breast irradiation (WBI) and accelerated partial breast irradiation (APBI) that shorten treatment duration to three and one week, respectively. Prospective randomized trials evaluating these techniques have been promising, demonstrating equivalence to traditional WBI with respect to clinical outcomes, toxicities, and breast cosmesis. Intraoperative radiation therapy (IORT) represents an alternative to these techniques that delivers treatment at the time of surgery as a single fraction of radiation (in the majority of cases). Increasingly, IORT is being offered to women with early-stage breast cancer as the definitive radiation therapy modality following breast conserving surgery. What is concerning is that these patients are being offered this, as yet, unproven therapy off-protocol with insufficient data to support its safety and efficacy compared with WBI or alternative techniques (APBI or hypofractionated WBI). This is unfortunate as radiation therapy in breast cancer represents an area of research that has undergone progress in the past five decades through systematic evidence-based treatment paradigm evolution; breast conserving therapy was verified via multiple randomized trials demonstrating comparable outcomes to mastectomy, and postmastectomy radiation therapy similarly demonstrated a survival benefit in several trials before wide-scale incorporation into treatment paradigms. Therefore, the rapid introduction of IORT is concerning as these steps have not been taken prior to wide-scale utilization, leading to a potential for higher rates of local recurrence or increased toxicity. It should be noted that two large randomized trials have been performed to evaluate the role of IORT in early-stage breast cancer compared with WBI, the current standard of care. The targeted intraoperative radiotherapy (TARGIT) trial was a randomized noninferiority trial that included 3,451 women enrolled in 10 countries between 2000 and 2012. Patients were randomized to IORT (delivered at the same time as surgery or as a separate procedure) or WBI; however, 21 % of the prepathology IORT patients received WBI because of predefined factors including lobular carcinoma in situ, extensive intraductal component, lymphovascular space invasion, node positivity, or other factors specific to each institution. IORT was delivered using a 50-kv X-ray source to deliver 20 Gy to the surface of the excision cavity (5 Gy at 1 cm). While initial data with short follow-up (median follow-up \2 years) and limited events (n = 11) was promising, a recent update found that IORT, even with WBI supplementation in one-fifth of the Society of Surgical Oncology 2013

Acute and late morbidity of using a breast positioning ring in women with large/pendulous breasts