John H Suh

Gamma Knife of Spokane, Spokane, Washington, United States

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Publications (224)712.29 Total impact

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    ABSTRACT: Large arteriovenous malformations (AVMs) of the head and neck present a treatment challenge. A 38-year-old woman presented with a large intraoral bleed from longstanding AVMs of the left infratemporal fossa and the right tongue, despite 10 prior surgeries and embolizations. She was treated with stereotactic body radiotherapy with a dose of 24 Gy in three weekly fractions. Four years later, she has had dramatic shrinkage of her AVM, no recurrent bleeding episodes, no further treatment required, and no significant late effects.Level of EvidenceNA Laryngoscope, 2014
    The Laryngoscope 09/2014; · 1.98 Impact Factor
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    ABSTRACT: Objective: We describe a patient with a large, invasive corticotroph adenoma who developed severe hypercortisolism shortly after starting fractionated radiotherapy.Method: We reviewed the patient's clinical course, along with relevant literature for similarly reported cases.Result: A 29-year-old man was referred for radiotherapy for a residual and recurrent, invasive corticotroph adenoma. Prior to the radiotherapy, he had normal urine free cortisol (UFC) 44.7 μg/24 hr with minimal symptoms. Within 2 weeks of radiotherapy, he developed hypertension, ankle edema, and hypokalemia (K 2.8 mEq/L), with markedly elevated UFC 9203 μg/24 hr. The UFC gradually decreased and normalized by the end of radiotherapy. A month later, the patient became adrenal insufficient with a non-detectable 24-hr urine free cortisol. His adrenal function slowly recovered in 3 months. We are aware of only one previous case report of clinically significant hypercortisolism following radiotherapy in Cushing disease.Conclusion: Radiotherapy may result in acute severe hypercortisolism in patients with a large corticotroph adenoma. This uncommon, but clinically significant, acute adverse effect of radiotherapy may suggest that clinical observation and biochemical monitoring during or soon after radiotherapy may be indicated.
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    ABSTRACT: SUMMARY Despite therapeutic advances in management, the prognosis of patients with brain metastasis remains dismal. Treatment options include surgical resection, whole brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS). Patients who undergo surgical resection typically receive WBRT as adjuvant therapy. However, several studies have demonstrated an association between WBRT and neurotoxicity. Thus, clinicians are increasingly delaying WBRT in favor of postoperative use of SRS. In this review, we will discuss the current literature exploring the efficacy and toxicity of postoperative SRS in the treatment of patients with resected brain metastasis.
    CNS oncology. 05/2014; 3(3):199-207.
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    ABSTRACT: Repeating whole-brain radiation therapy (WBRT) in patients with progressive/recurrent brain metastases is controversial. We retrospectively reviewed our experience of repeat WBRT in an era where stereotactic radiosurgery was also available. In our IRB-approved database, 49 patients received repeat WBRT from 1996 to 2011. Median initial dose of WBRT was 30 Gy in 10 fractions (range, 27 to 37.5 Gy); median reirradiation dose was 20 Gy in 10 fractions (range, 14 to 30 Gy). Median Karnofsky performance status (KPS) at reirradiation was 70 (range, 40 to 90). Median number of discrete lesions at reirradiation was 6 (range, 1 to 30). Median interval between initial diagnosis of brain metastases and relapse requiring repeat WBRT was 11.5 months (range, 1.5 to 49.2 mo). Overall survival and relapse-free survival were summarized using the Kaplan-Meier method. The log-rank test was used to compare outcomes between groups. Ninety percent of patients completed repeat WBRT. Median survival after repeat WBRT was 3 months (95% CI, 1.9-4.0). Thirteen patients had improved neurological symptoms (27%), 12 were stable (24%), and 14 had worsening symptoms (29%). On radiographic follow-up of 22 patients, 10 (46%) were improved, 4 (18%) were stable, and 8 (36%) progressed. Improved neurological symptoms after repeat WBRT and higher KPS at first follow-up were associated with improved survival (P=0.05 and 0.02). Repeat WBRT was well tolerated. Modest survival times are seen. Prognostic factors for survival include improved neurological symptoms after repeat WBRT and higher KPS at first follow-up. Repeat WBRT may be useful to improve neurological symptoms in patients with limited treatment options, especially those who are not appropriate stereotactic radiosurgery candidates.
    American journal of clinical oncology 03/2014; · 2.21 Impact Factor
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    ABSTRACT: Higher isodose lines (IDL) in Gamma Knife (GK) Perfexion treatment of brain metastases (BMet) could result in lower local control (LC) or higher radiation necrosis (RN) rates, but reduce treatment time. To assess impact of heterogeneity (HI) and conformality (CI) indices on local failure (LF) for patients treated with GK for 1-3 BMet. From an IRB-approved database, 320 patients with 496 BMet were identified, treated for 1-3 BMet from July 2007 to April 2011 on GK Perfexion. Cox proportional hazards regression was used to analyze significance of HI, CI, IDL, dose, tumor diameter, RPA class, tumor radioresistance, primary, smoking history, metastasis location, and WBRT history with LF and RN. Median follow-up by lesion was 6.8 months (range: 0-49.6). Series median survival was 14.2 months. Per RECIST, 9.5% of lesions failed, 33.9% were stable, 38.3% partially responded, 17.1% responded completely, and 1.2% could not be assessed. The 12-month LC rate was 87.3%. On univariate analysis, dose <20 Gy (HR=2.940, p<.001); tumor size (HR=1.674, p<.001); and cerebellum/brainstem location vs. other (HR=1.891, p=.043) were significant for LF. NSCLC (HR=.333, p=.0097) was associated with better LC. On multivariate analysis, tumor size (HR=1.696, p<.001) and cerebellum/brainstem location vs. other (HR=1.959, p=.033) remained significant for LF. Variables not significant for LF included CI, IDL, and HI. Our study of patients with 1-3 BMet treated with GK demonstrated no difference in LC or RN with varying HI, indicating that physicians can treat to IDL at ≥70% IDL to reduce treatment time without increased LF or RN.
    Neurosurgery 01/2014; · 2.53 Impact Factor
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    ABSTRACT: Purpose To review the impact of a workflow enhancement (WE) team in reducing treatment errors that reach patients within radiation oncology. Methods and Materials It was determined that flaws in our workflow and processes resulted in errors reaching the patient. The process improvement team (PIT) was developed in 2010 to reduce errors and was later modified in 2012 into the current WE team. Workflow issues and solutions were discussed in PIT and WE team meetings. Due to tensions within PIT that resulted in employee dissatisfaction, there was a 6-month hiatus between the end of PIT and initiation of the renamed/redesigned WE team. In addition to the PIT/WE team forms, the department had separate incident forms to document treatment errors reaching the patient. These incident forms are rapidly reviewed and monitored by our departmental and institutional quality and safety groups, reflecting how seriously these forms are treated. The number of these incident forms was compared before and after instituting the WE team. Results When PIT was disbanded, a number of errors seemed to occur in succession, requiring reinstitution and redesign of this team, rebranded the WE team. Interestingly, the number of incident forms per patient visits did not change when comparing 6 months during the PIT, 6 months during the hiatus, and the first 6 months after instituting the WE team (P=.85). However, 6 to 12 months after instituting the WE team, the number of incident forms per patient visits decreased (P=.028). After the WE team, employee satisfaction and commitment to quality increased as demonstrated by Gallup surveys, suggesting a correlation to the WE team. Conclusions A team focused on addressing workflow and improving processes can reduce the number of errors reaching the patient. Time is necessary before a reduction in errors reaching patients will be seen.
    International journal of radiation oncology, biology, physics 01/2014; · 4.59 Impact Factor
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    ABSTRACT: Current treatment modalities for central nervous system (CNS) metastases from renal cell cancer (RCC) include surgical resection, stereotactic radiosurgery (SRS), and whole-brain radiotherapy. Existing studies describing treatment outcomes for CNS metastases include multiple tumor types and thus provide little insight into how RCC CNS metastases respond to these modalities. RCC patients with brain metastases treated with SRS at the Cleveland Clinic between 1996 and 2010 were retrospectively identified. Radiosurgery and systemic therapy characteristics were recorded. Patients were followed up radiographically at 1 to 2 months after radiosurgery and every 3 to 6 months thereafter with magnetic resonance imaging scans. Of the 166 patients identified, local control was obtained in 90% of patients. In 38% of patients there were additional distant CNS metastases at a median of 12.8 months (95% CI, 8.5-21.1) after SRS. The median time to progression (either local or distant) was estimated to be 9.9 months (95% CI, 5.9-12.9). Higher (> 2.5) RCC-specific graded prognostic assessment (GPA) score was the only factor examined that was found to be a significant prognostic factor for improved outcome (P = .02); however, there was some suggestion that a single target lesion (P = .07) and age ≥ 60 years (P = .07) may also be associated with better CNS control. Stereotactic radiosurgery for a limited number of CNS metastases from RCC is associated with excellent local control and is an effective if not preferred treatment modality.
    Clinical Genitourinary Cancer 10/2013; · 1.43 Impact Factor
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    ABSTRACT: Although stereotactic radiosurgery (SRS) is an effective treatment option for patients with brain tumors, its increased use has raised concern for increased incidence of radiation necrosis (RN). No established standard or guidelines exists regarding non-invasive techniques to diagnose or treat RN. This study was conducted to assess current patterns of evaluation and treatment of RN among physicians who treat intracranial malignancies. A questionnaire consisting of 20 questions was sent to 3,041 members of the American Society for Radiation Oncology (ASTRO) and the Society for Neurologic Oncology (SNO). Questions addressed demographics, utilization of SRS, perceptions regarding RN diagnosis treatment, approach to steroid-refractory RN, and management of two clinical scenarios using Kwiksurvey© software. The survey response rate was 8.74 % (266/3,041). Most respondents practice in an academic and/or university setting (62 %) at a facility that performs SRS (94 %) with a variety of systems. The number of annual cases performed at the participant's institution varied from <50 to >400, with a wide degree of variability. Most respondents practice at an institution that performs 50-100 cases/year (28 %). The most common range of symptomatic RN seen in clinical practice was 1-5 % (61 %). Most respondents reported that asymptomatic RN occurs in 6-10 % (33 %). Favored non-invasive diagnostic mechanisms were clinical evaluation (37 %) and MRI (19 %). In response to a clinical scenario depicting an asymptomatic patient post-SRS for brain metastasis with an enlarging lesion and edema at the treatment site, most respondents felt the image represented RN or a combination of RN and tumor progression. Most (58 %) favored short-term follow-up with repeat MRI. Ninety-three percent of the respondents initiated steroids as a first-line approach if patient was to develop symptoms. Steroids were the preferred first therapy in symptomatic patients on initial follow-up (81 %). In steroid-refractory patients, most recommend surgical intervention (63 %). Most physicians who responded to this questionnaire believe that post-SRS RN is uncommon (≤10 % of cases). The approach to establish the diagnosis of RN is variable. Steroids are the most commonly utilized first-line treatment for suspected RN. Considerable variation exists in the management of steroid-refractory RN. Additional studies are required to establish guidelines for evaluation and treatment of RN.
    Journal of Neuro-Oncology 09/2013; · 3.12 Impact Factor
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    ABSTRACT: Therapeutic outcomes for patients with brain metastases need to improve. A critical review of trials specifically addressing brain metastases shows key issues that could prevent acceptance of results by regulatory agencies, including enrolment of heterogeneous groups of patients and varying definitions of clinical endpoints. Considerations specific to disease, modality, and treatment are not consistently addressed. Additionally, the schedule of CNS imaging and consequences of detection of new or progressive brain metastases in trials mainly exploring the extra-CNS activity of systemic drugs are highly variable. The Response Assessment in Neuro-Oncology (RANO) working group is an independent, international, collaborative effort to improve the design of trials in patients with brain tumours. In this two-part series, we review the state of clinical trials of brain metastases and suggest a consensus recommendation for the development of criteria for future clinical trials.
    The Lancet Oncology 09/2013; 14(10):396-406. · 25.12 Impact Factor
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    ABSTRACT: Neurocognitive function, neurological symptoms, functional independence, and health-related quality of life are major concerns for patients with brain metastases. The inclusion of these endpoints in trials of brain metastases and the methods by which these measures are assessed vary substantially. If functional independence or health-related quality of life are planned as key study outcomes, then the reliability and validity of these endpoints can be crucial because methodological issues might affect the interpretation and acceptance of findings. The Response Assessment in Neuro-Oncology (RANO) working group is an independent, international, and collaborative effort to improve the design of clinical trials in patients with brain tumours. In this report, the second in a two-part series, we review clinical trials of brain metastases in relation to measures of clinical benefit and provide a framework for the design and conduct of future trials.
    The Lancet Oncology 09/2013; 14(10):407-416. · 25.12 Impact Factor
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    ABSTRACT: Vertebral compression fracture (VCF) is increasingly recognized as an adverse event after spine stereotactic body radiotherapy (SBRT). We report a multi-institutional study aimed at clarifying the risk and predictive factors associated with VCF. A total of 252 patients with 410 spinal segments treated with SBRT were included. The primary outcome was the development of VCF (a new VCF or progression of a baseline VCF). In addition to various patient-, treatment-, and tumor-specific factors, the Spinal Instability Neoplastic Scoring (SINS) system was applied to determine predictive value. The median follow-up was 11.5 months (range, 0.03 to 113 months). The median and mean overall survival rates were 16 and 26 months, respectively. We observed 57 fractures (57 of 410, 14%), with 47% (27 of 57) new fractures and 53% (30 of 57) fracture progression. The median time to VCF was 2.46 months (range, 0.03 to 43.01 months), and 65% occurred within the first 4 months. The 1- and 2-year cumulative incidences of fracture were 12.35% and 13.49%, respectively. Multivariable analysis identified dose per fraction (greatest risk for ≥ 24 Gy v 20 to 23 Gy v ≤ 19 Gy), in addition to three of the six original SINS criteria: baseline VCF, lytic tumor, and spinal deformity, as significant predictors of VCF. Caution must be observed when treating with ≥ 20 Gy/fraction, in particular, for patients with lytic tumor, spinal misalignment, and a baseline VCF. Frequent short-term follow-up is required, as nearly two thirds of all VCF occurred within the first 4 months. We also conclude that SINS may have utility in predicting patients at high risk of SBRT-induced VCF.
    Journal of Clinical Oncology 08/2013; · 18.04 Impact Factor
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    ABSTRACT: Primary central nervous system lymphoma (PCNSL) is a type of extranodal non-Hodgkin lymphoma that involves only the central nervous system. Untreated PCNSL in the elderly has a rapidly fatal course. In this retrospective study, we evaluated the demographics, management, and outcomes of patients over 60 years of age with PCNSL at our institution. A total of 54 patients with a median age of 67 years were included in the analysis. The initial treatment regimens included whole-brain radiation therapy (WBRT), chemotherapy with or without consolidation WBRT. The median progression-free survival (PFS) was 8.0 months (95% confidence interval CI=2.7-22 months) and the median overall survival (OS) was 38 months (95% CI=18-65 months). On multivariable analysis, age younger than 70 years and Karnofsky Performance Status (KPS) no less than 70 were favorable prognostic factors for both OS and PFS. Aggressive treatment strategies for elderly patients with PCNSL with good performance status can lead to improved outcomes in this patient population.
    Anticancer research 08/2013; 33(8):3251-8. · 1.71 Impact Factor
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    ABSTRACT: Cerebral radiation necrosis (RN) is a devastating complication of radiation therapy for brain tumors. Recent studies have explored the role of bevacizumab, a humanized monoclonal antibody directed against vascular endothelial growth factor in the treatment of RN of the brain. We report 24 patients with cerebral RN who were treated with bevacizumab. Twenty-four patients diagnosed with cerebral RN and treated with different schedules of bevacizumab between July 2007 and June 2012, were identified from the Cleveland Clinic Brain Tumor and Neuro-Oncology Center's database. Pretreatment and posttreatment magnetic resonance imaging (MRI) studies were compared to evaluate bevacizumab efficacy. Posttreatment MRI demonstrated a radiographic improvement in 23 of 24 patients on the postcontrast T1-weighted MRI and fluid-attenuated inversion-recovery sequences. Using the McDonald criteria, the average change in the T1-weighted postcontrast MRI was a decrease of 48.1%, and the average change in the fluid-attenuated inversion-recovery images was a decrease of 53.7%. There was a mean daily dose reduction of 9.4 mg of dexamethasone after initiation of bevacizumab in patients who were on steroids at the start of bevaciuzmab therapy for RN. Treatment with bevacizumab was well tolerated with only 1 grade 3 adverse event. The current study demonstrates that bevacizumab treatment results in excellent clinical and radiologic response in patients with RN caused by common forms of radiation therapy. The safety profile of bevacizumab use in RN is acceptable. In the current study, we found no difference between different schedules of bevacizumab in treatment outcomes.
    American journal of clinical oncology 06/2013; · 2.21 Impact Factor
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    ABSTRACT: The incidence of radiation necrosis has increased secondary to greater use of combined modality therapy for brain tumors and stereotactic radiosurgery. Given that its characteristics on standard imaging are no different that tumor recurrence, it is difficult to diagnose without use of more sophisticated imaging and nuclear medicine scans, although the accuracy of such scans is controversial. Historically, treatment had been limited to steroids, hyperbaric oxygen, anticoagulants, and surgical resection. A recent prospective randomized study has confirmed the efficacy of bevacizumab in treating radiation necrosis. Novel therapies include using focused interstitial laser thermal therapy. This article will review the diagnosis and treatment of radiation necrosis.
    International journal of radiation oncology, biology, physics 06/2013; · 4.59 Impact Factor
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    ABSTRACT: SUMMARY Spine stereotactic body radiotherapy is based on delivering high biologically effective doses to spinal metastases, with the intent to maximize both tumor and pain control. The purpose of this review is to outline the technical details of spine stereotactic body radiotherapy, contrast clinical outcomes to low biologically effective dose conventional palliative radiotherapy, discuss the role of surgery in the era of spine stereotactic body radiotherapy, and summarize the major serious adverse events that patients would otherwise not be at risk of with conventional radiotherapy.
    CNS oncology. 05/2013; 2(3):259-270.
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    ABSTRACT: Our group has previously published the Diagnosis-Specific Graded Prognostic Assessment (GPA) showing the prognostic factors associated with survival in patients with brain metastases (BM). The purpose of this study is to investigate the relationship of breast cancer subtype to the time interval from primary diagnosis (PD) to development of BM (TPDBM), number of BM at initial BM presentation and survival. We analyzed our previously described multi-institutional retrospective database of 865 breast cancer patients treated for newly-diagnosed BM from 1993 to 2010. Several factors found to be associated with survival were incorporated into the Breast-GPA, including tumor subtype. The GPA database was further analyzed to determine if the subtype correlated with the TPDBM, number of BM, and survival from PD. After exclusions for incomplete data, 383 patients remained eligible for analysis. The subtypes were approximated as follows: Luminal B: triple positive; HER2: HER2 positive/ER/PR negative; Luminal A; ER/PR positive/HER2 negative; Basal: triple negative. Patients with Basal (90), HER2 (119), Luminal B (98) and Luminal A (76) tumor subtypes had a median TPDBM of 27.5, 35.8, 47.4 and 54.4 months (p < 0.01), median survival from PD of 39.6, 66.4, 90.3 and 72.7 months (p < 0.01) and median survival from BM of 7.3, 17.9, 22.9 and 10.0 months (p < 0.01), respectively. Tumor subtype is an important prognostic factor for survival in patients with breast cancer and BM. Although TPDBM is not an independent prognostic factor for survival (and thus not part of the Breast-GPA), the TPDBM does correlate with tumor subtype but does not correlate with the number of BM. Patients with Basal and HER2 tumor subtypes have short TPDBM. Prospective studies are needed to determine if screening brain MRIs are indicated in patients with Basal or HER2 subtypes.
    Journal of Neuro-Oncology 03/2013; · 3.12 Impact Factor
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    ABSTRACT: BACKGROUND: A phase 3 Radiation Therapy Oncology Group (RTOG) study subset analysis demonstrated improved overall survival (OS) with the addition of stereotactic radiosurgery (SRS) to whole brain radiation therapy (WBRT) in non-small cell lung cancer (NSCLC) patients with 1 to 3 brain metastases. Because temozolomide (TMZ) and erlotinib (ETN) cross the blood-brain barrier and have documented activity in NSCLC, a phase 3 study was designed to test whether these drugs would improve the OS associated with WBRT + SRS. METHODS AND MATERIALS: NSCLC patients with 1 to 3 brain metastases were randomized to receive WBRT (2.5 Gy × 15 to 37.5 Gy) and SRS alone, versus WBRT + SRS + TMZ (75 mg/m(2)/day × 21 days) or ETN (150 mg/day). ETN (150 mg/day) or TMZ (150-200 mg/m(2)/day × 5 days/month) could be continued for as long as 6 months after WBRT + SRS. The primary endpoint was OS. RESULTS: After 126 patients were enrolled, the study closed because of accrual limitations. The median survival times (MST) for WBRT + SRS, WBRT + SRS + TMZ, and WBRT + SRS + ETN were qualitatively different (13.4, 6.3, and 6.1 months, respectively), although the differences were not statistically significant. Time to central nervous system progression and performance status at 6 months were better in the WBRT + SRS arm. Grade 3 to 5 toxicity was 11%, 41%, and 49% in arms 1, 2, and 3, respectively (P<.001). CONCLUSION: The addition of TMZ or ETN to WBRT + SRS in NSCLC patients with 1 to 3 brain metastases did not improve survival and possibly had a deleterious effect. Because the analysis is underpowered, these data suggest but do not prove that increased toxicity was the cause of inferior survival in the drug arms.
    International journal of radiation oncology, biology, physics 02/2013; · 4.59 Impact Factor
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    ABSTRACT: BACKGROUND: The Radiation Therapy Oncology Group (RTOG) trial 97-14 revealed no difference between radiation delivered for painful bone metastases at a dose of 8 gray (Gy) in 1 fraction (single-fraction radiotherapy [SFRT]) and 30 Gy in 10 fractions (multifraction radiotherapy [MFRT]) in pain relief or narcotic use 3 months after randomization. SFRT for painful vertebral bone metastases (PVBM) has not been well accepted, possibly because of concerns about efficacy and toxicity. In the current study, the authors evaluated the subset of patients that was treated specifically for patients with PVBM. METHODS: PVBM included the cervical, thoracic, and/or lumbar spine regions. Among patients with PVBM, differences in retreatment rates and in pain relief, narcotic use, and toxicity 3 months after randomization were evaluated. RESULTS: Of 909 eligible patients, 235 (26%) had PVBM. Patients with and without PVBM differed in terms of the percentage of men (55% vs 47%, respectively; P = .03) and the proportion of patients with multiple painful sites (57% vs 38%, respectively; P < .01). Among those with PVBM, more patients who received MFRT had multiple sites treated (65% vs 49% for MFRT vs SFRT, respectively; P = .02). There were no statistically significant treatment differences in terms of pain relief (62% vs 70% for MFRT vs SFRT, respectively; P = .59) or freedom from narcotic use (24% vs 27%, respectively; P = .76) at 3 months. Significant differences in acute grade 2 through 4 toxicity (20% vs 10% for MFRT vs SFRT, respectively; P = .01) and acute grade 2 through 4 gastrointestinal toxicity (14% vs 6%, respectively; P = .01) were observed at 3 months, with lower toxicities seen in the patients treated with SFRT. Late toxicity was rare. No myelopathy was recorded. SFRT produced higher 3-year retreatment rates (5% vs 15%; P = .01). CONCLUSIONS: Results for the subset of patients with PVBM in the RTOG 94-17 randomized controlled trial were comparable to those for the entire population. SFRT produced less acute toxicity and a higher rate of retreatment than MFRT. SFRT and MFRT resulted in comparable pain relief and narcotic use at 3 months. Cancer 2012. © 2012 American Cancer Society.
    Cancer 11/2012; · 5.20 Impact Factor
  • International journal of radiation oncology, biology, physics 11/2012; 84(4):875-6. · 4.59 Impact Factor
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    ABSTRACT: Object Stereotactic body radiotherapy (SBRT) has emerged as an important treatment option for spinal metastases from renal cell carcinoma (RCC) as a means to overcome RCC's inherent radioresistance. The authors reviewed the outcomes of SBRT for the treatment of RCC metastases to the spine at their institution, and they identified factors associated with treatment failure. Methods Fifty-seven patients (88 treatment sites) with RCC metastases to the spine received single-fraction SBRT. Pain relief was based on the Brief Pain Inventory and was adjusted for narcotic use according to the Radiation Therapy Oncology Group protocol 0631. Toxicity was scored according to Common Toxicity Criteria for Adverse Events version 4.0. Radiographic failure was defined as infield or adjacent (within 1 vertebral body [VB]) failure on follow-up MRI. Multivariate analyses were performed to correlate outcomes with the following variables: epidural, paraspinal, single-level, or multilevel disease (2-5 sites); neural foramen involvement; and VB fracture prior to SBRT. Kaplan-Meier analysis and Cox proportional hazards modeling were used for statistical analysis. Results The median follow-up and survival periods were 5.4 months (range 0.3-38 months) and 8.3 months (range 1.5-38 months), respectively. The median time to radiographic failure and unadjusted pain progression were 26.5 and 26.0 months, respectively. The median time to pain relief (from date of simulation) and duration of pain relief (from date of treatment) were 0.9 months (range 0.1-4.4 months) and 5.4 months (range 0.1-37.4 months), respectively. Multivariate analyses demonstrated that multilevel disease (hazard ratio [HR] 3.5, p = 0.02) and neural foramen involvement (HR 3.4, p = 0.02) were correlated with radiographic failure; multilevel disease (HR 2.3, p = 0.056) and VB fracture (HR 2.4, p = 0.046) were correlated with unadjusted pain progression. One patient experienced Grade 3 nausea and vomiting; no other Grade 3 or 4 toxicities were observed. Twelve treatment sites (14%) were complicated by subsequent vertebral fractures. Conclusions Stereotactic body radiotherapy for RCC metastases to the spine offers fast and durable pain relief with minimal toxicity. Stereotactic body radiotherapy seems optimal for patients who have solitary or few spinal metastases. Patients with neural foramen involvement are at an increased risk for failure.
    Journal of neurosurgery. Spine 09/2012; · 1.61 Impact Factor

Publication Stats

3k Citations
712.29 Total Impact Points


  • 2011–2013
    • Gamma Knife of Spokane
      Spokane, Washington, United States
    • William Beaumont Army Medical Center
      El Paso, Texas, United States
    • Moffitt Cancer Center
      Tampa, Florida, United States
  • 2009–2012
    • Barrow Neurological Institute
      • Department of Neurosurgery
      Phoenix, AZ, United States
    • University of Minnesota Duluth
      Duluth, Minnesota, United States
  • 1997–2012
    • Case Western Reserve University
      • Department of Radiation Oncology (University Hospitals Case Medical Center)
      Cleveland, Ohio, United States
  • 1994–2012
    • Cleveland Clinic
      • • Department of Radiation Oncology
      • • Department of Neurosurgery
      Cleveland, Ohio, United States
  • 2004–2011
    • University of Wisconsin, Madison
      • Department of Human Oncology
      Madison, MS, United States
    • University of Maryland, Baltimore
      • Department of Radiation Oncology
      Baltimore, MD, United States
  • 2010
    • Washington University in St. Louis
      • Department of Radiation Oncology
      San Luis, Missouri, United States
  • 2008
    • Columbia University
      • College of Physicians and Surgeons
      New York City, NY, United States
  • 2007
    • University of South Florida
      Tampa, Florida, United States
    • University of Minnesota Twin Cities
      • Department of Neurosurgery
      Minneapolis, MN, United States
    • University of Pennsylvania
      • Department of Radiation Oncology
      Philadelphia, PA, United States
  • 2006
    • The University of Arizona
      • Department of Radiation Oncology
      Tucson, AZ, United States
  • 2005
    • Indiana University-Purdue University Indianapolis
      • Department of Radiation Oncology
      Indianapolis, IN, United States
  • 2002
    • Howard University Hospital
      Washington, Washington, D.C., United States
    • University of California, San Francisco
      • Department of Radiation Oncology
      San Francisco, CA, United States