Clifton D Fuller

Publications of Clifton D Fuller

• Distribution of the h-Index in Radiation Oncology Conforms to a Variation of Power Law: Implications for Assessing Academic Productivity.

  Authors: Matthew R Quigley, Emma B Holliday, Clifton D Fuller, Mehee Choi, Charles R Thomas

  Journal of cancer education : the official journal of the American Association for Cancer Education. 04/2012;

  Leaders of academic institutions evaluate academic productivity when deciding to hire, promote, or award resources. This study examined the distribution of the h-index, an assessment of academicLeaders of academic institutions evaluate academic productivity when deciding to hire, promote, or award resources. This study examined the distribution of the h-index, an assessment of academic standing, among radiation oncologists. The authors collected h-indices for 826 US academic radiation oncologists from a commercial bibliographic database (SCOPUS, Elsevier B.V., NL). Then, logarithmic transformation was performed on h-indices and ranked h-indices, and results were compared to estimates of a power law distribution. The h-index frequency distribution conformed to both the log-linear variation of a power law (r (2) = .99) and the beta distribution with the same fitting exponents as previously described in a power law analysis of the productivity of neurosurgeons. Within radiation oncology, as in neurosurgery, there are exceedingly more faculty with an h-index of 1-2. The distribution fitting the same variation of a power law within two fields suggests applicability to other areas of academia.

• Merkel Cell Carcinoma.

  Authors: Emma Ramahi, Jehee Choi, Clifton D Fuller, Tony Y Eng

  American journal of clinical oncology. 03/2011;

  Merkel cell carcinoma (MCC) is a rare, clinically aggressive cutaneous neuroendocrine neoplasm with a high mortality rate. Though the etiology is not precisely known, Merkel cell polyomavirus DNA hasMerkel cell carcinoma (MCC) is a rare, clinically aggressive cutaneous neuroendocrine neoplasm with a high mortality rate. Though the etiology is not precisely known, Merkel cell polyomavirus DNA has been found recently in a large percentage of MCC tumors. Other suggested risk factors include sun exposure, immunosuppression, and a history of prior malignancy. Work up of patients with MCC most notably includes nodal staging via clinical examination or sentinel lymph node biopsy. The prognosis for most patients with MCC is poor, and the rarity of MCC precludes the prospective, randomized clinical trials necessary to elucidate optimum treatment protocols. Most published data support the use of a multimodality approach centered around surgical excision with negative margins, sentinel lymph node biopsy to establish the presence or absence of nodal metastases, adjuvant radiothearpy to decrease the risk of recurrence, and systemic chemotherapy in the case of widespread disease.

• Prospective randomized double-blind pilot study of site-specific consensus atlas implementation for rectal cancer target volume delineation in the cooperative group setting.

  Authors: Clifton D Fuller, Jasper Nijkamp, Joop C Duppen, Coen R N Rasch, Charles R Thomas, Samuel J Wang, Paul Okunieff, William E Jones, Daniel Baseman, Shilpen Patel [......] Benjamin D Smith, Alan W Katz, Camille McGann, Jennifer L Harper, Daniel T Chang, Stephen Smalley, David T Marshall, Karyn A Goodman, Niko Papanikolaou, Lisa A Kachnic

  International journal of radiation oncology, biology, physics. 02/2011; 79(2):481-9.

  Variations in target volume delineation represent a significant hurdle in clinical trials involving conformal radiotherapy. We sought to determine the effect of a consensus guideline-based visualVariations in target volume delineation represent a significant hurdle in clinical trials involving conformal radiotherapy. We sought to determine the effect of a consensus guideline-based visual atlas on contouring the target volumes. A representative case was contoured (Scan 1) by 14 physician observers and a reference expert with and without target volume delineation instructions derived from a proposed rectal cancer clinical trial involving conformal radiotherapy. The gross tumor volume (GTV), and two clinical target volumes (CTVA, including the internal iliac, presacral, and perirectal nodes, and CTVB, which included the external iliac nodes) were contoured. The observers were randomly assigned to receipt (Group A) or nonreceipt (Group B) of a consensus guideline and atlas for anorectal cancers and then instructed to recontour the same case/images (Scan 2). Observer variation was analyzed volumetrically using the conformation number (CN, where CN = 1 equals total agreement). Of 14 evaluable contour sets (1 expert and 7 Group A and 6 Group B observers), greater agreement was found for the GTV (mean CN, 0.75) than for the CTVs (mean CN, 0.46-0.65). Atlas exposure for Group A led to significantly increased interobserver agreement for CTVA (mean initial CN, 0.68, after atlas use, 0.76; p = .03) and increased agreement with the expert reference (initial mean CN, 0.58; after atlas use, 0.69; p = .02). For the GTV and CTVB, neither the interobserver nor the expert agreement was altered after atlas exposure. Consensus guideline atlas implementation resulted in a detectable difference in interobserver agreement and a greater approximation of expert volumes for the CTVA but not for the GTV or CTVB in the specified case. Visual atlas inclusion should be considered as a feature in future clinical trials incorporating conformal RT.

• Effect of brain stem and dorsal vagus complex dosimetry on nausea and vomiting in head and neck intensity-modulated radiation therapy.

  Authors: Katherine Ciura, Michelle McBurney, Baongoc Nguyen, Mary Pham, Neal Rebueno, Clifton D Fuller, Nandita Guha-Thakurta, David I Rosenthal

  Medical dosimetry : official journal of the American Association of Medical Dosimetrists. 01/2011; 36(1):41-5.

  Intensity-modulated radiation therapy (IMRT) is becoming the treatment of choice for many head and neck cancer patients. IMRT reduces some toxicities by reducing radiation dose to uninvolved normalIntensity-modulated radiation therapy (IMRT) is becoming the treatment of choice for many head and neck cancer patients. IMRT reduces some toxicities by reducing radiation dose to uninvolved normal tissue near tumor targets; however, other tissues not irradiated using previous 3D techniques may receive clinically significant doses, causing undesirable side effects including nausea and vomiting (NV). Irradiation of the brainstem, and more specifically, the area postrema and dorsal vagal complex (DVC), has been linked to NV. We previously reported preliminary hypothesis-generating dose effects associated with NV in IMRT patients. The goal of this study is to relate brainstem dose to NV symptoms. We retrospectively studied 100 consecutive patients that were treated for oropharyngeal cancer with IMRT. We contoured the brainstem, area postrema, and DVC with the assistance of an expert diagnostic neuroradiologist. We correlated dosimetry for the 3 areas contoured with weekly NV rates during IMRT. NV rates were significantly higher for patients who received concurrent chemotherapy. Post hoc analysis demonstrated that chemoradiation cases exhibited a trend towards the same dose-response relationship with both brainstem mean dose (p = 0.0025) and area postrema mean dose (p = 0.004); however, both failed to meet statistical significance at the p ≤ 0.002 level. Duration of toxicity was also greater for chemoradiation patients, who averaged 3.3 weeks with reported Common Terminology Criteria for Adverse Events (CTC-AE), compared with an average of 2 weeks for definitive RT patients (p = 0.002). For definitive RT cases, no dose-response trend could be ascertained. The mean brainstem dose emerged as a key parameter of interest; however, no one dose parameter (mean/median/EUD) best correlated with NV. This study does not address extraneous factors that would affect NV incidence, including the use of antiemetics, nor chemotherapy dose schedule specifics before and during RT. A prospective study will be required to depict exactly how IMRT dose affects NV.

• Radiotherapy for thymic neoplasms.

  Authors: Clifton D Fuller, Emma H Ramahi, Noel Aherne, Tony Y Eng, Charles R Thomas

  Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 10/2010; 5(10 Suppl 4):S327-35.

  The role of radiotherapy in the treatment of thymoma and thymic carcinoma has been evaluated by many investigators over the past two decades. The low incidence of these neoplasms has limited mostThe role of radiotherapy in the treatment of thymoma and thymic carcinoma has been evaluated by many investigators over the past two decades. The low incidence of these neoplasms has limited most published studies to small series spanning long time intervals or population-based studies. The exact indications and protocols for the use of radiotherapy as a part of the multidisciplinary approach to thymoma and thymic carcinoma are still unclear. However, a review of recent literature shows potential benefits for certain patients based on stage and grade of disease as well as the extent of surgical resection.

• Conditional survival and the choice of conditioning set for patients with colon cancer: an analysis of NSABP trials C-03 through C-07.

  Authors: Beth A Zamboni, Greg Yothers, Mehee Choi, Clifton D Fuller, James J Dignam, Peter C Raich, Charles R Thomas, Michael J O'Connell, Norman Wolmark, Samuel J Wang

  Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 05/2010; 28(15):2544-8.

  Colon cancer overall survival (OS) is usually computed from the time of diagnosis. Survival gives the initial prognosis but does not reflect how prognosis changes with changing hazard rates overColon cancer overall survival (OS) is usually computed from the time of diagnosis. Survival gives the initial prognosis but does not reflect how prognosis changes with changing hazard rates over time. Conditional survival (probability of surviving y additional years given they have survived x years [CS or OS|OS]) is an alternative measure that accounts for elapsed time since diagnosis, providing more relevant prognostic information. We extend the concept of CS to condition on the set of patients alive, recurrence-free, and second primary cancer-free (disease-free survival [OS|DFS]). Using data from National Surgical Adjuvant Breast and Bowel Project trials C-03 through C-07, 5-year OS|DFS was calculated on patients who were disease free up to 5 years after diagnosis, stratified by age, stage, nodal status, and performance status (PS). For stage II, OS|DFS improved from 87% to 92% at 5 years. For stage III, OS|DFS improved from 69% to 88%. Patients younger than 50 years showed OS|DFS improvement from 79% to 95%; those older than 70 years showed no sustained increase in OS|DFS. Node-negative patients with > or = 12 nodes resected showed little change (89% to 94%); those with more than four positive nodes showed an improvement (57% to 86%). Patients with a PS of 0 or 1 demonstrated a small improvement; those with a PS of 2 did not (64% to 58%). Prognosis improves over time for almost all groups of patients with colon cancer, especially those with positive nodes. OS|DFS is a more relevant measure of prognosis for those who have already survived disease free a period of time after diagnosis.

• Chemoradiation for anal cancer: the more things change, the more they stay the same.

  Authors: Clifton D Fuller, Charles R Thomas

  Oncology (Williston Park, N.Y.). 04/2010; 24(5):427-30.

• Method comparison of automated matching software-assisted cone-beam CT and stereoscopic kilovoltage x-ray positional verification image-guided radiation therapy for head and neck cancer: a prospective analysis.

  Authors: Clifton D Fuller, Todd J Scarbrough, Jan-Jakob Sonke, Coen R N Rasch, Mehee Choi, Joe Y Ting, Samuel J Wang, Niko Papanikolaou, David I Rosenthal

  Physics in medicine and biology. 12/2009; 54(24):7401-15.

  We sought to characterize interchangeability and agreement between cone-beam computed tomography (CBCT) and digital stereoscopic kV x-ray (KVX) acquisition, two methods of isocenter positionalWe sought to characterize interchangeability and agreement between cone-beam computed tomography (CBCT) and digital stereoscopic kV x-ray (KVX) acquisition, two methods of isocenter positional verification currently used for IGRT of head and neck cancers (HNC). A cohort of 33 patients were near-simultaneously imaged by in-room KVX and CBCT. KVX and CBCT shifts were suggested using manufacturer software for the lateral (X), vertical (Y) and longitudinal (Z) dimensions. Intra-method repeatability, systematic and random error components were calculated for each imaging modality, as were recipe-based PTV expansion margins. Inter-method agreement in each axis was compared using limits of agreement (LOA) methodology, concordance analysis and orthogonal regression. 100 daily positional assessments were performed before daily therapy in 33 patients with head and neck cancer. Systematic error was greater for CBCT in all axes, with larger random error components in the Y- and Z-axis. Repeatability ranged from 9 to 14 mm for all axes, with CBCT showing greater repeatability in 2/3 axes. LOA showed paired shifts to agree 95% of the time within +/-11.3 mm in the X-axis, +/-9.4 mm in the Y-axis and +/-5.5 mm in the Z-axis. Concordance ranged from 'mediocre' to 'satisfactory'. Proportional bias was noted between paired X- and Z-axis measures, with a constant bias component in the Z-axis. Our data suggest non-negligible differences in software-derived CBCT and KVX image-guided directional shifts using formal method comparison statistics.A correction was made to the first line of page 7404 of this article on 26 November 2009. The corrected electronic version is identical to the print version.

• Report from the Radiation Therapy Committee of the Southwest Oncology Group (SWOG): Research Objectives Workshop 2008.

  Authors: Paul Okunieff, Lisa A Kachnic, Louis S Constine, Clifton D Fuller, Laurie E Gaspar, Daniel F Hayes, Jean Hooks, Clifton Ling, Frank L Meyskens, Philip A Philip, David Raben, Stephen R Smalley, Gregory P Swanson, Beverly A Teicher, Charles R Thomas, Bhadrasain Vikram, Michael J Zelefsky, Laurence H Baker

  Clinical cancer research : an official journal of the American Association for Cancer Research. 10/2009;

  Strategic planning for the Radiation Therapy Committee of the Southwest Oncology Group (SWOG) is comprehensively evaluated every six years in an effort to maintain a current and relevant scientificStrategic planning for the Radiation Therapy Committee of the Southwest Oncology Group (SWOG) is comprehensively evaluated every six years in an effort to maintain a current and relevant scientific focus, and to provide a standard platform for future development of protocol concepts. Participants in the 2008 Strategic Planning Workshop included clinical trial experts from multiple specialties, industry representatives from both pharmaceuticals and equipment manufacturers, and basic scientists. High-priority research areas such as image-guided radiation therapy for control of limited metastatic disease, analysis of biomarkers for treatment response and late toxicity, assessment of novel agents in combination with radiation, standardization of radiation target delineation, and the assessment of new imaging techniques to individualize cancer therapy, were discussed. Research priorities included clinical study designs featuring translational end points that identify patients most likely to benefit from combined modality therapy; intervention including combination radiation with standard chemotherapy; radiation with radiosensitizing molecular-targeted therapies; and stereotactic radiation for treatment of patients with regard to asymptomatic metastasis and radiation-induced tumor autoimmunity. The Committee concluded that the future research opportunities are among the most exciting to have developed in the last decade, and work is in progress to embark on these plans. (Clin Cancer Res 2009;15(18):OF1-8).

• Simple Carotid-Sparing Intensity-Modulated Radiotherapy Technique and Preliminary Experience for T1-2 Glottic Cancer.

  Authors: David I Rosenthal, Clifton D Fuller, Jerry L Barker, Bryan Mason, John A Garcia, Jan S Lewin, F Christopher Holsinger, C Richard Stasney, Steven J Frank, David L Schwartz, William H Morrison, Adam S Garden, K Kian Ang

  International journal of radiation oncology, biology, physics. 09/2009;

  PURPOSE: To investigate the dosimetry and feasibility of carotid-sparing intensity-modulated radiotherapy (IMRT) for early glottic cancer and to report preliminary clinical experience. METHODS ANDPURPOSE: To investigate the dosimetry and feasibility of carotid-sparing intensity-modulated radiotherapy (IMRT) for early glottic cancer and to report preliminary clinical experience. METHODS AND MATERIALS: Digital Imaging and Communications in Medicine radiotherapy (DICOM-RT) datasets from 6 T1-2 conventionally treated glottic cancer patients were used to create both conventional IMRT plans. We developed a simplified IMRT planning algorithm with three fields and limited segments. Conventional and IMRT plans were compared using generalized equivalent uniform dose and dose-volume parameters for in-field carotid arteries, target volumes, and organs at risk. We have treated 11 patients with this simplified IMRT technique. RESULTS: Intensity-modulated radiotherapy consistently reduced radiation dose to the carotid arteries (p < 0.05) while maintaining the clinical target volume coverage. With conventional planning, median carotid V35, V50, and V63 were 100%, 100%, and 69.0%, respectively. With IMRT planning these decreased to 2%, 0%, and 0%, respectively (p < 0.01). Radiation planning and treatment times were similar for conventional radiotherapy and IMRT. Treatment results have been excellent thus far. CONCLUSIONS: Intensity-modulated radiotherapy significantly reduced unnecessary radiation dose to the carotid arteries compared with conventional lateral fields while maintaining clinical target volume coverage. Further experience and longer follow-up will be required to demonstrate outcomes for cancer control and carotid artery effects.

• Multimodality therapy for locoregional extrahepatic cholangiocarcinoma : a population-based analysis.

  Authors: Clifton D Fuller, Samuel J Wang, Mehee Choi, Brian G Czito, John Cornell, Tania M Welzel, Katherine A McGlynn, Join Y Luh, Charles R Thomas

  Cancer. 08/2009;

  BACKGROUND:: Although surgical resection is the mainstay of treatment for extrahepatic cholangiocarcinoma, the majority of patients present with advanced disease. Due in part to numeric rarity, theBACKGROUND:: Although surgical resection is the mainstay of treatment for extrahepatic cholangiocarcinoma, the majority of patients present with advanced disease. Due in part to numeric rarity, the optimum role of radiotherapy (RT) for extrahepatic cholangiocarcinoma, as well as its relative benefit, is an area of debate. The specific aim of this series was to estimate survival for extrahepatic cholangiocarcinoma patients receiving surgery and adjuvant RT using a robust population-based data set. METHODS:: Data were extracted from the Surveillance, Epidemiology, and End Results (SEER) limited-use data set for selected extrahepatic cholangiocarcinoma cases. Lognormal multivariate survival analysis was implemented to estimate survival for patients for treatment cohorts based on extent of surgical intervention and RT. RESULTS:: Parametric estimated median survival for patients receiving total/radical resection + RT was 26 months; it was 25 months for total/radical resection alone, 25 months for subtotal/debulking resection + RT, 21 months for subtotal/debulking resection, 12 months for RT alone, and 9 months for those not receiving surgery or RT. Parametric multivariate analysis revealed age, American Joint Committee on Cancer Stage, grade, and surgical/radiation regimen as statistically significant covariates with survival. Surgery alone and adjuvant RT cohorts demonstrated evidence of improved survival compared with no treatment; comparatively, RT alone was associated with survival decrement. Early improvement in survival in adjuvant cohorts was not observed at later time points. CONCLUSIONS:: Survival estimates using SEER data suggest an early survival advantage for adjuvant RT for patients with locoregional extrahepatic cholangiocarcinoma. Although future prospective series are needed to confirm these observations, SEER data represent the largest domestic population-based extrahepatic cholangiocarcinoma cohort, and may provide useful baseline survival estimates for future studies. Cancer 2009. Published 2009 by the American Cancer Society.

• Increased vulnerability of the spinal cord to radiation or intrathecal chemotherapy during adolescence: A report from the Children's Oncology Group.

  Authors: Archie Bleyer, Mehee Choi, Samuel J Wang, Clifton D Fuller, R Beverly Raney

  Pediatric blood & cancer. 07/2009; 53(7):1205-1210.

  PURPOSE: To assess the rate of spinal cord toxicity in adolescents resulting from chemoradiotherapy of parameningeal sarcoma. METHODS AND MATERIALS: Of 152 patients with parameningeal sarcoma treatedPURPOSE: To assess the rate of spinal cord toxicity in adolescents resulting from chemoradiotherapy of parameningeal sarcoma. METHODS AND MATERIALS: Of 152 patients with parameningeal sarcoma treated per the Intergroup Rhabdomyosarcoma Study Group protocol from 1977 through 1989, eight developed paralyzing ascending myelitis after intrathecal chemotherapy with cytosine arabinoside, methotrexate, and hydrocortisone administered during and after radiation therapy to volumes that included part of the spinal cord. The eight cases include three not previously published. RESULTS: Of eight patients who developed CNS toxicity after intrathecal chemotherapy and radiotherapy for parameningeal rhabdomyosarcoma, all but one were between 13 and 18 years of age when treated. This severe toxicity occurred in one quarter of 28 adolescents treated with the regimen in comparison with one of 123 children 12 years of age or less (P < 0.0001), a rate that was as much as 30 times higher in the adolescents. Lengthening of the spinal cord during the pubertal growth spurt may account for the apparent increased vulnerability. CONCLUSIONS: Chemoradiotoxicity-associated spinal cord injury appears to be more likely to occur in adolescents than in younger or older ages. This observation appears to reverse a conventional wisdom in which the central nervous system is thought to become more resistant to the neurotoxic effects of chemoradiotherapy as it matures. Pediatr Blood Cancer 2009; 53:1205-1210. (c) 2009 Wiley-Liss, Inc.

• Bibliometric Analysis of Radiation Oncology Departmental Scholarly Publication Productivity at Domestic Residency Training Institutions.

  Authors: Clifton D Fuller, Mehee Choi, Charles R Thomas

  Journal of the American College of Radiology : JACR. 02/2009; 6(2):112-118.

  PURPOSE: Corporate scientific activity lies at the heart of the modern academic institution, and yet field-specific estimates of institutional or departmental scholarly productivity are difficult toPURPOSE: Corporate scientific activity lies at the heart of the modern academic institution, and yet field-specific estimates of institutional or departmental scholarly productivity are difficult to assess. The authors sought to estimate long-term and current departmental research efforts at residency-sponsoring US radiation oncology departments, using modifications of established bibliometric indices. METHODS: Bibliometric citation database searches were performed for all residency-affiliated academic radiation oncology departments and their component physician radiation oncology faculty members. Metrics based on publication, citation, and the Hirsch index (h-index) were calculated, and departments were ranked by departmental productivity from 1996 to 2007, as well as by current mean faculty bibliometric output. RESULTS: Seventy-eight academic radiation oncology departments and their component 826 radiation oncologist faculty members were analyzed bibliometrically. The average number of publications per department from 1996 to 2007 was 363.8, with a mean of 8,116.0 citations and a mean institutional h-index of 37.2. Departments at academic institutions demonstrated a grand mean of 41.0 publications, 709.0 citations, and an h-index of 7.6 as of fall 2007. A larger number of physician faculty members (>12) was associated with increased scholarly activity. CONCLUSIONS: The use of quantitative metrics provides departments and researchers with a mechanism to evaluate collective scientific productivity and serves as an impetus for improved performance across the field.

• Estimation of Citation-Based Scholarly Activity Among Radiation Oncology Faculty at Domestic Residency-Training Institutions: 1996-2007.

  Authors: Mehee Choi, Clifton D Fuller, Charles R Thomas

  International journal of radiation oncology, biology, physics. 12/2008;

  PURPOSE: Advancement in academic radiation oncology is largely contingent on research productivity and the perceived external influence of an individual's scholarly work. The purpose of this studyPURPOSE: Advancement in academic radiation oncology is largely contingent on research productivity and the perceived external influence of an individual's scholarly work. The purpose of this study was to use the Hirsch index (h-index) to estimate the research productivity of current radiation oncology faculty at U.S. academic institutions between 1996 and 2007. METHODS AND MATERIALS: We performed bibliometric citation database searches for available radiation oncology faculty at domestic residency-training institutions (n = 826). The outcomes analyzed included the total number of manuscripts, total number of citations, and the h-index between 1996 and 2007. Analysis of overall h-index rankings with stratification by academic ranking, junior vs. senior faculty status, and gender was performed. RESULTS: Of the 826 radiation oncologists, the mean h-index was 8.5. Of the individuals in the top 10% by the h-index, 34% were chairpersons, 88% were senior faculty, and 13% were women. A greater h-index was associated with a higher academic ranking and senior faculty status. Recursive partitioning analysis revealed an h-index threshold of 15 (p <0.0001) as an identified breakpoint between the senior and junior faculty. Overall, women had lower h-indexes compared with men (mean, 6.4 vs. 9.4); however, when stratified by academic ranking, the gender differential all but disappeared. CONCLUSION: Using the h-index as a partial surrogate for research productivity, it appears that radiation oncologists in academia today comprise a prolific group, however, with a highly skewed distribution. According to the present analysis, the h-index correlated with academic ranking. Thus, it potentially has utility in the process of promotion decisions. Overall, women in radiation oncology were less academically productive than men; the possible reasons for the gender differential are discussed.

• Effect of body mass index on shifts in ultrasound-based image-guided intensity-modulated radiation therapy for abdominal malignancies.

  Authors: Mehee Choi, Clifton D Fuller, Samuel J Wang, Ather Siddiqi, Adrian Wong, Charles R Thomas, Martin Fuss

  Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology. 10/2008;

  BACKGROUND AND PURPOSE: We investigated whether corrective shifts determined by daily ultrasound-based image-guidance correlate with body mass index (BMI) of patients treated with image-guidedBACKGROUND AND PURPOSE: We investigated whether corrective shifts determined by daily ultrasound-based image-guidance correlate with body mass index (BMI) of patients treated with image-guided intensity-modulated radiation therapy (IG-IMRT) for abdominal malignancies. The utility of daily image-guidance, particularly for patients with BMI>25.0, is examined. MATERIALS AND METHODS: Total 3162 ultrasound-directed shifts were performed in 86 patients. Direction and magnitude of shifts were correlated with pretreatment BMI. Bivariate statistical analysis and analysis of set-up correction data were performed using systematic and random error calculations. RESULTS: Total 2040 daily alignments were performed. Average 3D vector of set-up correction for all patients was 12.1mm/fraction. Directional and absolute shifts and 3D vector length were significantly different between BMI cohorts. 3D displacement averaged 4.9mm/fraction and 6.8mm/fraction for BMI25.0 and BMI>25.0, respectively. Systematic error in all axes and 3D vector was significantly greater for BMI>25.0. Differences in random error were not statistically significant. CONCLUSIONS: Set-up corrections derived from daily ultrasound-based IG-IMRT of abdominal tumors correlated with BMI. Daily image-guidance may improve precision of IMRT delivery with benefits assessed for the entire population, particularly patients with increased habitus. Requisite PTV margins suggested in the absence of daily image-guidance are significantly greater in patients with BMI>25.0.

• Conditional survival in ovarian cancer: results from the SEER dataset 1988-2001.

  Authors: Mehee Choi, Clifton D Fuller, Charles R Thomas, Samuel J Wang

  Gynecologic oncology. 06/2008; 109(2):203-9.

  OBJECTIVES: Survival statistics for patients with ovarian cancer are typically reported in terms of survival from time of diagnosis. For patients who have survived a period of time since diagnosis,OBJECTIVES: Survival statistics for patients with ovarian cancer are typically reported in terms of survival from time of diagnosis. For patients who have survived a period of time since diagnosis, however, conditional survival (CS) is a more clinically relevant measure, as it accounts for the changes in risk over time. The purpose of this study was to estimate CS for ovarian cancer patients through analysis of large-scale cancer registry data. METHODS: Ovarian cancer cases were extracted from the Surveillance, Epidemiology, and End Results (SEER 17) database from the National Cancer Institute (NCI) for patients diagnosed between 1988-2001. Five-year relative CS calculations were performed with stratification by age, race, stage, histology, and grade for patients who had already survived up to 5 years from diagnosis. RESULTS: The 5-year overall relative CS improved over time for up to 5 years after diagnosis for ovarian cancer patients. The largest gains in CS over time were seen for patients with advanced stage disease, poor grade, and serous and undifferentiated epithelioid histologies. For patients with stage IV disease, 5-year CS more than tripled over the first 5 years of surveillance (17%-56%). Among histological types, patients with undifferentiated epithelioid histology saw 5-year CS rise from 29% at diagnosis to 84% after 5 years. CONCLUSIONS: Prognosis improves over time for almost all groups of ovarian cancer patients. For ovarian cancer survivors, CS provides a more relevant measure of prognosis than conventional survival estimates that are made at the time of diagnosis.

• Beam Path Toxicities to Non-Target Structures During Intensity-Modulated Radiation Therapy for Head And Neck Cancer.

  Authors: David I Rosenthal, Mark S Chambers, Clifton D Fuller, Neal C S Rebueno, John Garcia, Merrill S Kies, William H Morrison, K Kian Ang, Adam S Garden

  International journal of radiation oncology, biology, physics. 05/2008;

  BACKGROUND: Intensity-modulated radiation therapy (IMRT) beams traverse nontarget normal structures not irradiated during three-dimensional conformal RT (3D-CRT) for head and neck cancer (HNC). ThisBACKGROUND: Intensity-modulated radiation therapy (IMRT) beams traverse nontarget normal structures not irradiated during three-dimensional conformal RT (3D-CRT) for head and neck cancer (HNC). This study estimates the doses and toxicities to nontarget structures during IMRT. MATERIALS AND METHODS: Oropharyngeal cancer IMRT and 3D-CRT cases were reviewed. Dose-volume histograms (DVH) were used to evaluate radiation dose to the lip, cochlea, brainstem, occipital scalp, and segments of the mandible. Toxicity rates were compared for 3D-CRT, IMRT alone, or IMRT with concurrent cisplatin. Descriptive statistics and exploratory recursive partitioning analysis were used to estimate dose "breakpoints" associated with observed toxicities. RESULTS: A total of 160 patients were evaluated for toxicity; 60 had detailed DVH evaluation and 15 had 3D-CRT plan comparison. Comparing IMRT with 3D-CRT, there was significant (p </= 0.002) nonparametric differential dose to all clinically significant structures of interest. Thirty percent of IMRT patients had headaches and 40% had occipital scalp alopecia. A total of 76% and 38% of patients treated with IMRT alone had nausea and vomiting, compared with 99% and 68%, respectively, of those with concurrent cisplatin. IMRT had a markedly distinct toxicity profile than 3D-CRT. In recursive partitioning analysis, National Cancer Institute's Common Toxicity Criteria adverse effects 3.0 nausea and vomiting, scalp alopecia and anterior mucositis were associated with reconstructed mean brainstem dose >36 Gy, occipital scalp dose >30 Gy, and anterior mandible dose >34 Gy, respectively. CONCLUSIONS: Dose reduction to specified structures during IMRT implies an increased beam path dose to alternate nontarget structures that may result in clinical toxicities that were uncommon with previous, less conformal approaches. These findings have implications for IMRT treatment planning and research, toxicity assessment, and multidisciplinary patient management.

• Prospective Evaluation of Pretreatment Executive Cognitive Impairment and Depression in Patients Referred for Radiotherapy.

  Authors: Clifton D Fuller, Jason E Schillerstrom, William E Jones, Melissa Boersma, Donald R Royall, Martin Fuss

  International journal of radiation oncology, biology, physics. 05/2008;

  PURPOSE: Cancer patients are at risk of cognitive impairment and depression. We sought to ascertain the prevalence of executive, visuospatial, memory, and general cognitive performance deficitsPURPOSE: Cancer patients are at risk of cognitive impairment and depression. We sought to ascertain the prevalence of executive, visuospatial, memory, and general cognitive performance deficits before radiotherapy in a radiation oncology clinic referral population and correlate the neurocognitive measures with the depression symptom burden. METHODS AND MATERIALS: A total of 122 sequential patients referred for radiotherapy evaluation were administered a test battery composed of the Executive Interview (EXIT25), Executive Clock Drawing Task (CLOX1 and CLOX2), Mini Mental State Examination (MMSE), Memory Impairment Screen (MIS), and Geriatric Depression Scale (GDS). The mean age +/- standard deviation was 58 +/- 17 years. Of 122 patients, 24 (20%) had been referred for breast cancer, 21 (17%) for gastrointestinal cancer, 17 (14%) for genitourinary disease, and 8 (7%) for brain lesions; the rest were a variety of tumor sites. The cognitive performance among the tumor cohorts was compared using Bonferroni-corrected analysis of variance and Tukey-Kramer tests. Pearson correlation coefficients were determined between each cognitive instrument and the GDS. RESULTS: Of the 122 patients, 52 (43%) exhibited a detectable executive cognition decrement on one or more test measures. Five percent had poor memory performance (MIS), 18% had poor visuospatial performance (CLOX2), and 13% had poor global cognition (MMSE). Patients with brain tumors performed substantially worse on the EXIT25. No between-group differences were found for CLOX1, CLOX2, MIS, or GDS performance. The EXIT25 scores correlated significantly with the GDS scores (r = 0.26, p = 0.005). CONCLUSIONS: The results of this study have shown that patients referred for radiotherapy exhibit cognitive impairment profiles comparable to those observed in acutely ill medical inpatients. Executive control impairment appears more prevalent than global cognitive deficits, visuospatial impairment, or depression.

• A cost-effectiveness analysis of adjuvant chemoradiotherapy for resected gastric cancer.

  Authors: Samuel J Wang, Clifton D Fuller, Mehee Choi, Charles R Thomas

  Gastrointestinal cancer research : GCR. 04/2008; 2(2):57-63.

  BACKGROUND: The Intergroup 0116 trial demonstrated that adding postoperative chemoradiotherapy for gastric cancer resulted in a significant overall survival improvement of 9 months. The purpose ofBACKGROUND: The Intergroup 0116 trial demonstrated that adding postoperative chemoradiotherapy for gastric cancer resulted in a significant overall survival improvement of 9 months. The purpose of this study was to perform a cost-effectiveness analysis of adjuvant chemoradiotherapy for resected gastric cancer. METHODS: An economic model was constructed to examine the costs and quality-adjusted survival benefit of adjuvant chemoradiotherapy for gastric cancer. Medicare reimbursement rates were used for chemotherapy and radiotherapy costs. Costs of managing toxicities were also included. Patient utilities were derived from published literature. The analysis was performed from the third-party payer perspective, with results reported in 2007 US dollars. A lifetime time horizon and 3% discount rate were used. One-way and Monte Carlo probabilistic sensitivity analyses were performed. RESULTS: For the base case, the incremental cost of adding adjuvant chemoradiotherapy was $20,100. The net gain in quality-adjusted life years (QALYs) was 0.53. The incremental cost-effectiveness ratio (ICER) was $38,400/QALY. The probabilistic sensitivity analysis predicted a 67% likelihood that the ICER would be less than $50,000/QALY. CONCLUSION: Our model suggests that the ICER of adjuvant chemoradiotherapy for resected gastric cancer compares favorably to other widely used cancer treatments.

• A comprehensive review of the treatment of Merkel cell carcinoma.

  Authors: Tony Y Eng, Melisa G Boersma, Clifton D Fuller, Virginia Goytia, William E Jones, Melissa Joyner, Dominic D Nguyen

  American journal of clinical oncology. 01/2008; 30(6):624-36.

  Merkel cell carcinoma (MCC) is an uncommon but malignant cutaneous neuroendocrine carcinoma with a high incidence of local recurrence, regional lymph node metastases, and subsequent distantMerkel cell carcinoma (MCC) is an uncommon but malignant cutaneous neuroendocrine carcinoma with a high incidence of local recurrence, regional lymph node metastases, and subsequent distant metastases. The etiology of MCC remains unknown. It usually occurs in sun-exposed areas in elderly people, many of whom have a history of other synchronous or metachronous sun-associated skin lesions. The outcome for most patients with MCC is generally poor. Surgery is the mainstay of treatment. The role of adjuvant therapy has been debated. However, data from recent development support a multimodality approach, including surgical excision of primary tumor with adequate margins and sentinel lymph node dissection followed by postoperative radiotherapy in most cases, as current choice of practice with better locoregional control and disease-free survival. Patients with regional nodal involvement or advanced disease should undergo nodal dissection followed by adjuvant radiotherapy and, perhaps, systemic platinum-based chemotherapy in most cases.