We report the clinical outcomes of a randomized trial comparing prophylactic whole-pelvic nodal radiotherapy to prostate-only radiotherapy (PORT) in high-risk prostate cancer.
This phase III, single ...center, randomized controlled trial enrolled eligible patients undergoing radical radiotherapy for node-negative prostate adenocarcinoma, with estimated nodal risk ≥ 20%. Randomization was 1:1 to PORT (68 Gy/25# to prostate) or whole-pelvic radiotherapy (WPRT, 68 Gy/25# to prostate, 50 Gy/25# to pelvic nodes, including common iliac) using computerized stratified block randomization, stratified by Gleason score, type of androgen deprivation, prostate-specific antigen at diagnosis, and prior transurethral resection of the prostate. All patients received image-guided, intensity-modulated radiotherapy and minimum 2 years of androgen deprivation therapy. The primary end point was 5-year biochemical failure-free survival (BFFS), and secondary end points were disease-free survival (DFS) and overall survival (OS).
From November 2011 to August 2017, a total of 224 patients were randomly assigned (PORT = 114, WPRT = 110). At a median follow-up of 68 months, 36 biochemical failures (PORT = 25, WPRT = 7) and 24 deaths (PORT = 13, WPRT = 11) were recorded. Five-year BFFS was 95.0% (95% CI, 88.4 to 97.9) with WPRT versus 81.2% (95% CI, 71.6 to 87.8) with PORT, with an unadjusted hazard ratio (HR) of 0.23 (95% CI, 0.10 to 0.52;
< .0001). WPRT also showed higher 5-year DFS (89.5%
77.2%; HR, 0.40; 95% CI, 0.22 to 0.73;
= .002), but 5-year OS did not appear to differ (92.5%
90.8%; HR, 0.92; 95% CI, 0.41 to 2.05;
= .83). Distant metastasis-free survival was also higher with WPRT (95.9%
89.2%; HR, 0.35; 95% CI, 0.15 to 0.82;
= .01). Benefit in BFFS and DFS was maintained across prognostic subgroups.
Prophylactic pelvic irradiation for high-risk, locally advanced prostate cancer improved BFFS and DFS as compared with PORT, but OS did not appear to differ.
Staging of a bone sarcoma before initiating treatment helps orthopaedic oncologists determine the intent of treatment and predicting the prognosis. As per National Comprehensive Cancer Network (NCCN) ...and European Society for Medical Oncology (ESMO) guidelines, there are no exclusive recommendations for chondrosarcoma staging. They are staged similar to other bone sarcomas even though skeletal metastases are extremely rare in chondrosarcomas.
We asked: (1) What proportion of patients with a chondrosarcoma present with detectable only skeletal metastasis? (2) What proportion of patients with chondrosarcoma present with skeletal metastasis with or without concurrent pulmonary metastases?
Between January 2006 to December 2017, 480 patients with histology-proven chondrosarcomas of the extremity, including clavicle, scapula, spine, and pelvis, presented to our institute. Fifty-three patients were excluded due to incomplete details about their staging. The remaining 427 were retrospectively analyzed and included in this study. Their clinical, radiological, and histopathological details were retrieved from patient files and electronic medical records. Of the 427 patients included, 53 had Grade 1 chondrosarcoma, 330 had Grade 2 chondrosarcoma, and 41 had Grade 3 chondrosarcoma. Grade was not available in three patients. All patients were staged with a thoracic CT scan and bone scan or a whole body fluorodeoxyglucose positron-emission tomography/CT (FDG PET/CT). Patients with a suspected or documented metastasis were reviewed again by an experienced radiologist and a nuclear medicine expert for the purpose of this study. A total of 8% (35 of 427) of patients with chondrosarcoma had isolated lung metastases at the time of initial staging. These included 9% (31 of 330) of patients with Grade 2 chondrosarcomas and 10% (4 of 41) of patients with Grade 3 chondrosarcomas. No patient with a Grade 1 chondrosarcoma had detectable lung metastases. The primary study endpoint was the number of patients who had a diagnosis of skeletal or skeletal and lung metastases as identified by the staging modalities.
Three patients with Grade 2 chondrosarcoma had only skeletal metastasis. No patients with Grade 1 or Grade 3 chondrosarcoma had detectable bone metastases. Combined lung and bone metastases were seen in only two patients with Grade 2 chondrosarcoma.
Our study found that the incidence of bony metastasis in conventional chondrosarcomas is extremely low. Considering the present results, we believe skeletal scanning may be overused in current staging algorithms. We do not have survival outcomes to know if detecting these few patients with skeletal lesions at initial presentation would be important in the absence of symptoms, but our data suggest that omitting skeletal imaging from the staging work-up of conventional chondrosarcomas should be considered. It may be reserved for patients with documented pulmonary metastases.
Level IV, diagnostic study.
Purpose
Our objective was to conduct a systematic review and meta-analysis of studies assessing the diagnostic performance of
18
F-fluorodeoxyglucose positron emission tomography (FDG PET) with or ...without computed tomography (CT) in post-treatment response assessment and/or surveillance imaging of head and neck squamous cell carcinoma (HNSCC).
Methods
A systematic search of the indexed medical literature was done using appropriate keywords to identify relevant studies. Metrics of diagnostic test accuracy, viz. sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were extracted from individual studies and combined using a random effects model to yield weighted mean pooled estimates with 95% confidence intervals (95% CI). The impact of timing of post-treatment scan, study quality and advancements in PET technology was explored through meta-regression.
Results
A total of 51 studies involving 2,335 patients were included in the meta-analysis. The weighted mean (95% CI) pooled sensitivity, specificity, PPV and NPV of post-treatment FDG PET(CT) for the primary site was 79.9% (73.7–85.2%), 87.5% (85.2–89.5%), 58.6% (52.6–64.5%) and 95.1% (93.5–96.5%), respectively. Similar estimates for the neck were 72.7% (66.6–78.2%), 87.6% (85.7–89.3%), 52.1% (46.6–57.6%) and 94.5% (93.1–95.7%), respectively. Scans done ≥12 weeks after completion of definitive therapy had moderately higher diagnostic accuracy on meta-regression analysis using time as a covariate.
Conclusion
The overall diagnostic performance of post-treatment FDG PET(CT) for response assessment and surveillance imaging of HNSCC is good, but its PPV is somewhat suboptimal. Its NPV remains exceptionally high and a negative post-treatment scan is highly suggestive of absence of viable disease that can guide therapeutic decision-making. Timing of post-treatment imaging has a significant, though moderate impact on diagnostic accuracy.
The 2015 American Thyroid Association (ATA) guideline have suggested modifications in the risk stratification (RS) for differentiated thyroid cancer (DTC) patients, introduced the concept of dynamic ...risk stratification (DRS) and redefined the role of radioactive iodine (RAI) in treatment algorithm. The aim of this retrospective audit was to assess the practical implications of these modifications in management of DTC.
Methods
A total of 138 DTC patients were stratified according to ATA 2009 and 2015 guidelines into low (LR), intermediate (IR) and high (HR) risk groups. Change in RS and in intention of RAI use was calculated. Deviation in administered RAI dosage from the guidelines was assessed. 1-year follow-up data was audited to assess how the DRS modified the initial risk estimate.
Results
A total of 11.6% of patients changed their RS categories in 2015 guidelines. A total of 10.1% got upstaged to HR, and 1.4% got downstaged to LR. In 2.17% of patients’ intention of RAI use changed to remnant ablation from adjuvant therapy and 65% of the LR patients won’t require any RAI therapy. A total of 26.7% of patients had received significantly more RAI dosage according to ATA 2015. At 1-year follow-up according to DRS 84% of LR, 75% of IR and 44% of HR patients showed excellent response (ER).
Conclusion
More patients changed RS to HR than to LR. Intention of RAI use changed in only a small number of patients. Significantly higher dosage of RAI is being administered to patients in current practice. The effect of DRS in modifying the initial RS was most prominent in IR, with most showing ER to initial therapy.
Purpose
To analyze diagnostic performance of F-18 FDG PET/CT in recurrent adenocarcinoma gallbladder (GBC) and to establish its possible impact on post-recurrence survival.
Method
FDG PET/CT studies ...of suspected recurrent GBC were retrospectively analyzed alongside tumor markers serum CEA and CA 19-9. Abnormal FDG-avid lesions and abnormal morphological lesions were considered positive for recurrence, and were categorized as isolated abdominal wall recurrence, loco-regional recurrence, and distant metastatic disease. Histopathology, definite progression on imaging and positive response to treatment was considered as reference standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were used as diagnostic performance parameters. Post-recurrence survival was calculated whenever appropriate follow-up was available, based on the abovementioned categories of sites of recurrence using survival curves and log-rank test.
Results
Out of 117 PET/CT studies, 93 (79.5%) were positive and 24 (20.5%) were negative for recurrence. 86 out of 93 were true positive and 23 of 24 were true negative. PET/CT demonstrated sensitivity, specificity, PPV, NPV and accuracy of 98.8%, 76.7%, 92.5%, 95.8% and 93.1%, respectively. Diagnostic performance of PET/CT was significantly better than combination tumor markers. Of 66 cases with available follow-up, isolated abdominal wall (port/scar site) recurrence and loco-regional recurrence demonstrated significantly higher post-recurrence survival as compared to distant metastasis; median survival being 39, 25 and 12 months, respectively.
Conclusion
F-18 FDG PET/CT has better diagnostic performance than tumor markers combination. Isolated abdominal wall (port/scar site) recurrence and loco-regional recurrence on PET/CT demonstrated better survival than non-regional metastatic disease. These results suggest a possible role of PET/CT as a surveillance modality, as well as a guide to therapeutic decision-making in cases of recurrent GBC.
Abstract
Lung cancer is one of the leading causes of cancer-related deaths. Accurate assessment of disease extent is important in deciding the optimal treatment approach. To play an important role in ...the multidisciplinary management of lung cancer patients, it is necessary that the radiologist understands the principles of staging and the implications of radiological findings on the various staging descriptors and eventual treatment decisions.
Abstract
18Fluorine-2-fluoro-2-Deoxy-d-glucose (18 F-FDG) positron emission tomography/computerized tomography (PET/CT) is a well-established functional imaging method widely used in oncology. In ...this article, we have incorporated the various indications for18 FDG PET/CT in oncology based on available evidence and current guidelines. Growing body of evidence for use of18 FDG PET/CT in select tumors is also discussed. This article attempts to give the reader an overview of the appropriateness of using18 F-FDG PET/CT in various malignancies.
Purpose
Locally advanced (T3/T4) gallbladder cancers with large fixed portal nodes have a dismal prognosis. If undertaken, surgery entails extensive resections with high morbidity; therefore, in many ...centers, patients are offered palliative chemotherapy. In this prospective study, we used neoadjuvant concurrent chemoradiation with the intention of downstaging and facilitating R0 resection of these tumors.
Patients and Methods
Twenty-eight patients with locally advanced carcinoma gallbladder (stage III, having deep liver infiltrations and/or large portal nodes) underwent prior positron emission tomography/computed tomography to rule out metastatic disease. All were treated with concomitant chemoradiation using helical tomotherapy (dose of 57 Gy over 25 fractions to the gross tumor and 45 Gy over 25 fractions to the surrounding nodes) with injectable gemcitabine (300 mg/m
2
/week × 5 weeks).
Results
Of the 28 patients, 25 (89 %) successfully completed planned chemoradiation and 20 (71 %) achieved partial or complete radiologic response. Eighteen (64 %) patients were surgically explored, of whom 14 (56 %) achieved R0 resection. At the median follow-up of 37 months for the surviving patients, the median overall survival (OS) was 20 months for all patients. Only one patient recurred in the common bile duct postsurgery, whereas six patients had distant metastasis. The 5-year OS was 24 % for all patients and 47 % for patients with R0 resection. Biliary leak was seen in 6 (43 %) patients, of whom two required interventions.
Conclusion
Locally advanced unresectable cancers may benefit from neoadjuvant chemoradiation to facilitate a curative resection with a good survival.
Purpose
177
Lu-DOTATATE therapy is an effective treatment strategy for the treatment of neuroendocrine tumours. However, it could cause severe side effects in major critical organs. Therefore, ...individual dosimetry is essential for the safety and treatment of patients. Multiple imaging time points (4–6 time points) post administration of radioactivity can be used to obtain the best fit for dosimetric calculations, however, this is a tedious and time-consuming process. In this study, we aimed to reduce the number of imaging time points to three and optimized them for less cumbersome organ dosimetry.
Methods
In this retrospective study, the images from 40 patients with neuroendocrine tumors were analysed. Sequential planar whole-body scans were acquired at five time points (0.5, 4, 24, 72/96 and 160 h) post administration of
177
Lu-DOTATATE, which was considered the standard data set for dosimetry. Subsequently, seven subsets of three different time points (T1-0.5,4,24 h; T2-4,24,72/96 h; T3-0.5,4,160 h; T4-4,24,160 h; T5- 24,72/96,160 h; T6- 4,72/96,160 h; T7-0.5,4,72/96 h) were generated using standard data set. For each of these, normalized cumulative activity (NCA) and absorbed dose (AD) for kidneys, liver, spleen, lung, and tumours were estimated using Dosimetry Toolkit (GE Healthcare, Chicago, IL) and OLINDA EXM v.2 software respectively.
Results
The best three correlation coefficients of AD (mGy/MBq) of the standard data set with subsets were 0.74 (T2), 0.71(T6), 0.94 (T7) respectively for kidneys; 0.80(T3), 0.64(T6), 0.77(T7) respectively for spleen; 0.99(T3), 0.98(T6), 0.99(T7) respectively for liver; 0.63(T3), 0.62(T4), 0.75(T7) for lung and 0.92(T3), 0.90(T6), 0.96(T7) for tumours respectively.
Conclusion
It was demonstrated that organ dosimetry with three-time point imaging can be as accurate as standard imaging when the imaging three time points are chosen optimally. The imaging subset of T7 (0.5, 4 and 72/96 h) produced the best results for organs and tumour lesions compared to other subsets.
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