[Show abstract][Hide abstract] ABSTRACT: Objectives:
We report our series of skull base chordoma patients who underwent surgical resection followed by high-dose fractionated stereotactic radiotherapy (FSRT) as an alternative to proton radiotherapy (RT).
Between 2002 and 2009, 12 patients with skull base chordomas without prior radiation history were treated with adjuvant or salvage RT. FSRT with dynamic conformal arcs and intensity-modulated radiation therapy boost was used until 2006 when image-guided intensity-modulated FSRT was instituted. Median dose of 66.6 Gy (range, 48.6 to 68.4 Gy) was delivered in 180 cGy fractions prescribed to the 90% isodose line that covered the target volume to achieve a median isocenter dose of 74 Gy (range, 54 to 76 Gy).
Median follow-up was 42 months. Median time from surgery to initiation of RT was 3.6 months. Overall survival was 76.4% at 5 years, and 46.9% and 37.5% of patients were free of progression at 24 and 60 months, respectively. Six patients had disease progression after radiation with a median time to progression of 17.3 months. One patient was salvaged with radiosurgery and surgical resection, with stable disease almost 7 years since diagnosis. Two patients were salvaged with molecular targeted therapy with stable disease at 20 and 23 months. At last follow-up, 9 patients had stable or reduced disease.
FSRT as postoperative treatment of skull base chordomas resulted in promising overall survival results comparable with the published literature of particle therapy without significant complications. Our technique for treating skull base chordomas can be considered a safe and less costly alternative to proton RT.
American journal of clinical oncology 07/2012; 36(4). DOI:10.1097/COC.0b013e318248dc6f · 3.06 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We review the current systems of health care delivery for the treatment of substance use disorders and examine the expansion of addiction treatment to include new methods and settings, supported by changing technology, new financing/payment mechanisms, and expanded information management processes. We examine 3 subsets of patients who should be able to receive better, more frequent care through recent federally mandated health care reform. Finally, we provide recommendations for what we consider essential steps to facilitate the improvement of care for substance use disorders under health care reform.
The Psychiatric clinics of North America 06/2012; 35(2):327-56. DOI:10.1016/j.psc.2012.03.004 · 1.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a previous article, the authors described the changes initiated by recent health care legislation, and how those changes might affect the practice of medicine and the delivery of addiction services. This article reviews the same changes with respect to how they have the potential to change the practice activities of addiction physicians, addiction therapists, addiction counselors and addiction nurses, as well as the activities of administrators and service delivery financial personnel. Developments in delivery systems and the impact of those developments on professionals who work in addiction treatment are considered; current problems, potential solutions, and opportunities for clinicians under health reform are addressed. The goals envisioned for health system reform and the potential for realization of those goals via changes in addiction service delivery design and clinical practice are discussed.