Chandana A Reddy

Cleveland Clinic, Cleveland, Ohio, United States

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Publications (251)905.15 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The patterns of intracranial failure in patients with brain metastasis from pulmonary neuroendocrine carcinoma (PNEC) remain unknown. From 1998 to 2013, 29 patients with the diagnosis of PNEC were treated for brain metastasis: 16 patients (55%) underwent whole-brain radiation therapy (WBRT), 5 (17%) patients underwent WBRT with a stereotactic radiosurgery (SRS) boost, and 8 (28%) patients underwent primary SRS alone. The median age at treatment was 61 years (range: 44-84 years) and the median follow-up was 9.6 months (0-157.4 months). Of the patients treated with SRS alone, 1 patient had radiographic local progression of disease and 1 patient had a distant intracranial failure. Of the patients treated with WBRT with or without an SRS boost, 9 patients developed intracranial progression, including 1 local failure. No differences in rates of intracranial progression or local failure between the 2 groups (P = .94 and P = .44, respectively) were observed. The actuarial rates of distant intracranial failure at 12 months were 32.9% (95% confidence interval [95% CI] 8.9%-56.8%) and 25% (95% CI 0.0%-67.4%) in patients undergoing primary WBRT or SRS, respectively (P = .31). The median overall survival was 15.8 months in patients treated with WBRT and 20.4 months in patients treated with primary SRS (P = .78). Patients with brain metastasis from PNECs can be effectively treated with either WBRT or SRS alone, with a pattern of failure more consistent with non-small cell lung cancer than small cell lung cancer. In this series, there was not a statistically significant increased risk of distant intracranial failure when patients were treated with primary SRS. © The Author(s) 2015.
    Technology in cancer research & treatment 06/2015; DOI:10.1177/1533034615589033 · 1.94 Impact Factor
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    ABSTRACT: Severe late dysphagia (SLD) is common after chemoradiation (CRT) for cancers of the larynx and oropharynx. Options for reduction of SLD are limited for HPV-negative patients. Here the role of feeding tube (FT) choice in SLD is investigated. Patients disease-free after CRT for HPV-negative cancers of the laryngopharynx who received a FT on-treatment were identified. The incidence of SLD after reactive nasogastric (R-NG), proactive or reactive percutaneous gastrostomy (P-PEG and R-PEG) was assessed using log-rank and Cox analyses. 78 patients received a FT on-treatment and remained disease-free. Median follow-up was 64 months. The 5-year incidence of SLD was 30.8% in the R-NG cohort (n=36), 56.4% in the R-PEG (n=17, p=0.193) and 60.9% in the P-PEG (n=25, p=0.016) cohorts. On multivariate analysis, PEG feeding was independently associated with an increased rate of SLD. R-NG use during chemoradiation is associated with less SLD and is preferred over PEG. This article is protected by copyright. All rights reserved. © 2015 Wiley Periodicals, Inc.
    Head & Neck 06/2015; DOI:10.1002/hed.24157 · 3.01 Impact Factor
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    ABSTRACT: Definitive resection of primary rectal cancers is frequently incorporated, with or without preoperative radiotherapy and perioperative chemotherapy, in the management of selected patients with metastatic rectal adenocarcinoma. This study reviews the impact of preoperative radiotherapy and perioperative chemotherapy on locoregional recurrence and overall survival in these patients. This retrospective study with an Institutional Review Board (IRB) waiver included 109 patients with metastatic rectal adenocarcinoma who underwent definitive primary resection between 1998 and 2011. In addition to resection, 64 patients were treated with preoperative radiotherapy and perioperative chemotherapy and 45 patients were treated with perioperative chemotherapy alone. Radiotherapy dose was typically 50.4 Gy. Baseline variables were compared using chi-square and unpaired t tests. Overall survival was calculated using Kaplan-Meier method. Univariate and multivariate analyses were performed using Cox proportional hazards regression. There were no significant baseline differences between the two groups. There was no significant difference in locoregional recurrence (10.9 vs. 11.1 %; p = 0.90) or overall survival (34.5 vs. 34.8 months; p = 0.89) for patients treated with preoperative radiotherapy compared to those treated with perioperative chemotherapy alone, respectively. Patients who underwent radiotherapy were less likely to have a positive margin (10.9 vs. 20.0 %; p = 0.19), lymphovascular invasion (32.8 vs. 53.3 %; p = 0.03), and pathologic stage N2 disease (25.0 vs. 42.2 %; p = 0.02). Grade 2 postoperative complications were more common in the preoperative radiotherapy group (32.8 vs. 15.6 %; p = 0.04). Multivariate analysis demonstrated that patients with poorly differentiated tumors (HR 2.19; p = 0.009) and those that did not undergo liver-directed therapy (HR 2.20; p = 0.005) had inferior survival. Locoregional recurrence is modest in patients with metastatic rectal adenocarcinoma receiving definitive primary resection, irrespective of the use of radiotherapy. Preoperative radiotherapy may enhance pathologic downstaging at the expense of increased grade 2 postoperative complications. Its use should be reserved for patients at high risk for locoregional recurrence.
    Journal of Gastrointestinal Surgery 05/2015; DOI:10.1007/s11605-015-2861-9 · 2.39 Impact Factor
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    ABSTRACT: To report long-term efficacy and toxicity for a single-institution cohort of patients treated with low-dose-rate prostate brachytherapy permanent implant (PI) monotherapy. From 1996 to 2007, 1989 patients with low-risk (61.3%), intermediate-risk (29.8%), high-intermediate-risk (4.5%), and high-risk prostate cancer (4.4%) were treated with PI and followed up prospectively in a registry. All patients were treated with (125)I monotherapy to 144 Gy. Late toxicity was coded retrospectively according to a modified Common Terminology Criteria for Adverse Events 4.0 scale. The rates of biochemical relapse-free survival (bRFS), distant metastasis-free survival (DMFS), overall survival (OS), and prostate cancer-specific mortality (PCSM) were calculated. We identified factors associated with late grade ≥3 genitourinary (GU) and gastrointestinal (GI) toxicity, bRFS, DMFS, OS, PCSM, and incontinence. The median age of the patients was 67 years, and the median overall and prostate-specific antigen follow-up times were 6.8 years and 5.8 years, respectively. The overall 5-year rates for bRFS, DMFS, OS, and PCSM were 91.9%, 97.8%, 93.7%, and 0.71%, respectively. The 10-year rates were 81.5%, 91.5%, 76.1%, and 2.5%, respectively. The overall rates of late grade ≥3 GU and GI toxicity were 7.6% and 0.8%, respectively. On multivariable analysis, age and prostate length were significantly associated with increased risk of late grade ≥3 GU toxicity. The risk of incontinence was highly correlated with both pre-PI and post-PI transurethral resection of the prostate. Prostate brachytherapy as monotherapy is an effective treatment for low-risk and low-intermediate-risk prostate cancer and appears promising as a treatment for high-intermediate-risk and high-risk prostate cancer. Significant long-term toxicities are rare when brachytherapy is performed as monotherapy. Copyright © 2015 Elsevier Inc. All rights reserved.
    International journal of radiation oncology, biology, physics 05/2015; DOI:10.1016/j.ijrobp.2015.02.047 · 4.18 Impact Factor
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    ABSTRACT: A prognostic model for 5-year overall survival (OS) consisting of a recursive partitioning analysis (RPA) and nomogram, was developed for patients with early stage non-small cell lung cancer (ES-NSCLC) treated with stereotactic ablative radiotherapy (SABR).
    International journal of radiation oncology, biology, physics 05/2015; DOI:10.1016/j.ijrobp.2015.05.003 · 4.18 Impact Factor
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    ABSTRACT: To ascertain the safety and efficacy of permanent prostate brachytherapy (PPB) in early prostate cancer patients who have undergone previous total proctocolectomy and J-pouch anastomosis for inflammatory bowel disease. We identified 10 patients with a previous history of prostate cancer and J-pouch anastomosis from our institutional review board-approved database. Seven patients had PPB and 3 had prostatectomy. Only patients treated with PPB were included. Patient records were reviewed to collect data on treatment-related toxicity and oncological outcomes. All 7 patients who underwent PPB had low- to intermediate-risk prostate cancer. The mean prostatic volume was 24.40 mL and the average number of iodine-125 seeds implanted was 84. Postimplant dosimetric calculations showed a mean prostate volume receiving 100% of the prescribed dose (V100) of 88.76%, V150 of 45.23%, V200 of 16.79%, radiation dose delivered to 90% of the prostate of 147.89 Gy, volume of ileal pouch receiving 100% of the prescribed dose of 0.164 mL, and volume of ileal pouch receiving 50% of the prescribed dose of 1.38 mL. After a mean follow-up of 19 months, none of the patients had evidence of biochemical failure or clinical failure. There were no long-term genitourinary side effects detected. Two patients had Common Terminology Criteria for Adverse Events version 4.0 grade II gastrointestinal side effects, of which symptoms resolved to baseline in 1 patient, whereas the other patient progressed to chronic active enteritis (pouchitis). Low- to intermediate-risk prostate cancer patients with J-pouch anastomosis after total colectomy for inflammatory bowel disease are candidates for definitive treatment with PPB. Caution should be exercised while deploying the most posterior row of seeds to minimize enteral pouch radiation doses. Copyright © 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
    04/2015; DOI:10.1016/j.prro.2015.03.002
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    ABSTRACT: To examine the influence of zone-specific dosimetry on outcomes during permanent prostate implantation (PI), where the peripheral zone (PZ) and transitional zone (TZ) may receive varying radiation doses. Four hundred and sixteen patients treated with I-125 PI (target dose: 144 Gy) between 1996 and 2003 were included in this Institutional Review Board (IRB) approved, retrospective analysis. Whole prostate (WP), TZ, and PZ were contoured, and zone-specific D90 and V100 were computed. Their influence on biochemical failure (BF) was evaluated using Cox proportional hazards analysis. The median age and initial prostate-specific antigen (PSA) was 68 years and 6.1 ng/ml, respectively, and the median follow-up time was 8.8 years. There were 329 subjects with Gleason score (GS) 6 disease (79.1%), and 82 subjects had GS 7 disease (19.7%). Androgen deprivation therapy (ADT) was used in 20.4% of patients. Median D90 and V100% in the WP, PZ, and TZ were 141.2 Gy, 156.1 Gy, and 134.5 Gy; and 88.8%, 93.3%, and 84.2%, respectively. Ten-year rates for biochemical recurrence-free survival, distant metastasis-free survival, and prostate cancer-specific mortality were 82.4%, 92.4%, and 0.97% respectively. Only initial PSA, GS7+ disease, ADT, and PSA frequency were significant on multivariate analysis. Ten-year rates of grade 3 or higher GU and GI toxicity was 10.9% and 1.8%, respectively. TZ V200 and TZ V300 were significantly associated with late genitourinary toxicity. The TZ received significantly lower doses of radiation compared to the PZ. On multivariate analysis, no dosimetric parameter was associated with efficacy. Higher TZ doses may be associated with higher late GU toxicity without improving efficacy.
    Journal of Contemporary Brachytherapy 02/2015; 7(1):17-22. DOI:10.5114/jcb.2015.48875
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    ABSTRACT: Androgen deprivation therapy (ADT) is typically provided neoadjuvantly and concurrently with radiotherapy (RT) in the management of intermediate and high-risk prostate cancer. Our objective was to compare outcomes between patients who received adjuvant ADT (ADJ), ie, immediately after the completion of RT, to those who received a neoadjuvant and concurrent regimen (NEO). From 1995 to 2002, 515 patients with prostate cancer were definitively treated with RT and ADT. NEO was provided 2 to 3 months before the start of RT (n = 311). ADJ was initiated immediately after the completion of RT (n = 204). Kaplan-Meier analysis was used to calculate biochemical relapse-free survival (bRFS), distant metastasis-free survival (DMFS), and overall survival (OS). Cox proportional hazards regression was used to examine the impact of ADT timing on outcomes. Ten-year bRFS, DMFS, and OS rates were 61%, 80%, and 66%, respectively. Ten-year bRFS rates for ADJ versus NEO were 63% versus 60% (P = .98). Ten-year DMFS rates for ADJ versus NEO were both 80% (P = .60). Ten-year OS rates for ADJ versus NEO were 65% versus 67% (P = .98). There was no significant difference in bRFS, DMFS, or OS between neoadjuvant versus adjuvant ADT in the setting of dose-escalated RT for localized prostate cancer. This suggests that the synergy between RT and androgen deprivation is independent of the sequencing of both modalities and that the initiation of RT does not need to be delayed for a course of neoadjuvant ADT. Copyright © 2015 Elsevier Inc. All rights reserved.
    Clinical Genitourinary Cancer 12/2014; 13(3). DOI:10.1016/j.clgc.2014.12.009 · 1.69 Impact Factor
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    ABSTRACT: Object Traditionally, the treatment of choice for patients with metastases to the calvaria or skull base has been conventional radiation therapy. Because patients with systemic malignancies are also at risk for intracranial metastases, the utility of Gamma Knife surgery (GKS) for these patients has been explored to reduce excess radiation exposure to the perilesional brain parenchyma. The purpose of this study was to report the efficacy of GKS for the treatment of calvarial metastases and skull base lesions. Methods The authors performed a retrospective chart review of 21 patients with at least 1 calvarial or skull base metastatic lesion treated with GKS during 2001-2013. For 7 calvarial lesions, a novel technique, in which a bolus was placed over the treatment site, was used. For determination of local control or disease progression, radiation therapy data were examined and posttreatment MR images and oncology records were reviewed. Survival times from the date of procedure were estimated by using Kaplan-Meier analyses. Results The median patient age at treatment was 57 years (range 29-84 years). A total of 19 (90%) patients received treatment for single lesions, 1 patient received treatment for 3 lesions, and 1 patient received treatment for 4 lesions. The most common primary tumor was breast cancer (24% of patients). Per lesion, the median clinical and radiographic follow-up times were 10.3 months (range 0-71.9 months) and 7.1 months (range 0-61.3 months), respectively. Of the 26 lesions analyzed, 14 (54%) were located in calvarial bones and 12 (46%) were located in the skull base. The median lesion volume was 5.3 cm(3) (range 0.3-55.6 cm(3)), and the median prescription margin dose was 15 Gy (range 13-24 Gy). The median overall survival time for all patients was 35.9 months, and the 1-year local control rate was 88.9% (95% CI 74.4%-100%). Local control rates did not differ between lesions treated with the bolus technique and those treated with traditional methods or between calvarial lesions and skull base lesions (p > 0.05). Of the 3 patients for whom local treatment failed, 1 patient received no further treatment and 2 patients responded to salvage chemotherapy. Subsequent brain parenchymal metastases developed in 2 patients, who then underwent GKS. Conclusions GKS is an effective treatment modality for patients with metastases to the calvarial bones or skull base. For patients with superficial calvarial lesions, a novel approach with bolus application resulted in excellent rates of local control. GKS provides an effective therapeutic alternative to conventional radiation therapy and should be considered for patients at risk for calvarial metastases and brain parenchymal metastases.
  • International journal of radiation oncology, biology, physics 11/2014; 90(5). DOI:10.1016/j.ijrobp.2014.08.155 · 4.18 Impact Factor
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    ABSTRACT: Introduction: To examine regional nodal failure patterns with respect to lesion size in medically inoperable early-stage non-small cell lung cancer (NSCLC) patients treated with definitive lung stereotactic body radiation therapy (SBRT). Methods: Between 2004 and 2012, 342 medically inoperable early-stage NSCLC patients treated with definitive SBRT were identified in our institutional review board-approved prospective registry. All patients were treated on a Novalis/BrainLAB system using ExacTrac for image guidance. Kaplan-Meier analysis was performed with the log-rank test used to detect differences between lesion size and nodal failure patterns. Cox-proportional hazard regression analysis was performed to identify predictors of nodal failure. Results: Median follow-up was 17.6 months (range, 0-84 months). Median tumor size, positron emission tomography maximum standardized uptake value, and dose/fractionation were 2.2 cm (range, 0.8-7.2 cm), 6.7 (range, 1-59), and 50 Gray (Gy)/five fractions, respectively. Of the 342 lesions evaluated, 14.6% (50 of 342) experienced nodal failure. Nodal failure rates were 17.45% (26 of 149), 10.3% (11 of 107), 14.1% (10 of 71), and 20% (3 of 15) for lesions less than or equal to 2 cm, 2.1 to 3 cm, 3.1 to 5 cm, and greater than 5 cm, respectively. Rates of nodal failure were not significantly different between the four different size groups (p = 0.15). On univariate analysis, 2.1 to 3 cm lesions versus less than or equal to 2 cm exhibited less nodal failure after SBRT (hazard ratio = 0.406; 95% confidence interval = 0.189-0.87; p = 0.0205). No other patient, tumor, or treatment factor significantly affected nodal failure. Conclusion: For early-stage NSCLC treated with SBRT, tumor size does not influence the rates of regional nodal failure. This finding warrants further investigation on the possible mechanisms of SBRT by which loco-regional control is improved.
    Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 09/2014; 9(11). DOI:10.1097/JTO.0000000000000313 · 5.80 Impact Factor
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    ABSTRACT: To identify factors associated with grade ≥3 treatment related late esophageal toxicity after lung or liver stereotactic body radiation therapy (SBRT).
    International journal of radiation oncology, biology, physics 07/2014; 90(1). DOI:10.1016/j.ijrobp.2014.05.011 · 4.18 Impact Factor
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    ABSTRACT: Purpose: To review outcomes of 2 single-fraction lung stereotactic body radiation therapy (SBRT) schedules used for medically inoperable early stage lung cancer. Methods and Materials: Patients in our institution have been treated on and off protocols using single-fraction SBRT (30 Gy and 34 Gy, respectively). All patients had node-negative lung cancer measuring <= 5 cm and lying >= 2 cm beyond the trachea-bronchial tree and were treated on a Novalis/BrainLAB system with the ExactTrac positioning system for daily image guidance. Results: For the interval from 2009 to 2012, 80 patients with 82 lesions were treated with single-fraction lung SBRT. Fifty-five patients (69%) and 25 patients (31%) received 30 Gy and 34 Gy, respectively. In a comparison of 30 Gy and 34 Gy cohorts, patient and tumor characteristics were balanced and median follow-up in months was 18.7 and 17.8, respectively. The average heterogeneity-corrected mean doses to the target were 33.75 Gy and 37.94 Gy for the 30-Gy and 34-Gy prescriptions, respectively. Comparing 30-Gy and 34-Gy cohorts, 92.7% and 84.0% of patients, respectively, experienced no toxicity (P was not significant), and had neither grade 3 nor higher toxicities. For the 30-Gy and 34-Gy patients, rates of 1-year local failure, overall survival, and lung cancer-specific mortality were 2.0% versus 13.8%, 75.0% versus 64.0%, and 2.1% versus 16.0%, respectively (P values for differences were not significant). Conclusions: This is the largest single-fraction lung SBRT series yet reported. and it confirms the safety, efficacy, and minimal toxicity of this schedule for inoperable early stage lung cancer. (C) 2014 Elsevier Inc.
    International journal of radiation oncology, biology, physics 07/2014; 90(1). DOI:10.1016/j.ijrobp.2014.05.017 · 4.18 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 07/2014; 89(4). DOI:10.1016/j.ijrobp.2014.01.024 · 4.18 Impact Factor
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    ABSTRACT: Background Prostate cancer is the most common non-cutaneous malignancy diagnosed in men. From a large population-based database, we aim to report prostate cancer specific mortality (PCSM) rates of men diagnosed with various presentations of prostate cancer in order to examine the adequacy of the current American Joint Committee on Cancer (AJCC) staging system. Methods The Surveillance, Epidemiology, and End Results (SEER) database was queried for all patients diagnosed with prostate cancer from 1997 – 2005. PCSM was reported by extent of disease (EOD) classification provided by the SEER database, for clinically staged and pathologically staged cohorts. Results Using the cumulative incidence method, PCSM at 10 years for all patients (n=354,326) was 5% in clinically localized (CL) lesions, 7% in T3aN0M0, 14% T3bN0M0, 26% for T4N0M0, 27% for TanyN1M0 and 66% for TanyNanyM1 disease. Within the pathologically staged subgroup (n=108,135), PCSM at 10 years was 1% in clinically localized (CL) lesions, 4% in T3aN0M0, 9% T3bN0M0, 9% for T4N0M0 and 19% for TanyN1M0. Conclusion Staging of any disease site aims to accurately communicate, prognosticate and guide management for that particular level of disease. Stage IV prostate cancer is a diverse group with PCSM in the subgroups ranging from 9 to 68% in this study. Considering the favorable outcomes of those with T4 or N1 non-metastatic prostate cancer relative to those with M1 disease, we propose a new stage IIIB in which T4 or N1 M0 prostate cancer should be reclassified, and patients offered curative intent therapy whenever possible.
    Clinical Genitourinary Cancer 07/2014; 13(1). DOI:10.1016/j.clgc.2014.07.003 · 1.69 Impact Factor
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    ABSTRACT: Objective This study aims to report on patients (pts) with potentially resectable pleural mesothelioma treated with induction chemotherapy (CT) followed by extrapleural pneumonectomy (EPP) and adjuvant intensity-modulated radiation therapy (IMRT). Methods From 2002 to 2008 a retrospective review found 16 consecutive mesothelioma pts planned for trimodality care. CT involved a platinum-based doublet. EPP was carried out after pt restaging. IMRT to a dose of 54 Gy was given at least 4 weeks after EPP. Study endpoints included toxicity, dosimetric parameters, time to recurrence, and survival. Results Two pts progressed during CT and did not undergo EPP. One pt died after surgery. Thirteen pts (81 %) completed all treatments. Concerning IMRT, the mean of mean lung doses (MLDs) was 9.28 Gy. The mean percent of lung volume receiving 5 Gy (V5) and 20 Gy (V20) was 81.3 and 5.0 %, respectively. Acute radiation pulmonary toxicities included two grade 3 events. V30 was significantly associated with ≥grade 2 pulmonary toxicity (p = 0.041). There were no pulmonary-related deaths. Mean follow-up from CT start for 16 pts was 17.7 months (range, 1.3 to 66.3). Median survival (MS) was 20.2 months for pts completing therapy. Actuarial overall survival at 3 years was 31.6 %. Pathologic nodal stage did not correlate with overall or recurrence-free survival. Median time to local and/or distant recurrence from CT start was 15.3 months for pts completing therapy. All pts with local and regional failures also had distant failure. Two pts failed distantly only. Conclusion IMRT resulted in minimal pulmonary toxicity. Local control and survival remain challenging despite trimodality care.
    06/2014; 3(2):159-166. DOI:10.1007/s13566-014-0142-y
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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; DOI:10.1097/COC.0000000000000051 · 2.61 Impact Factor
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    ABSTRACT: Exposure to ionizing radiation has been linked to myelodysplastic syndromes (MDS); it is not clear whether therapeutic radiation doses used for prostate cancer pose an increased MDS risk. We performed a retrospective cohort study of prostate cancer patients diagnosed between 1986 and 2011 at Cleveland Clinic, comparing those who underwent definitive treatment with radical prostatectomy (RP) to radiotherapy either external beam radiotherapy (EBRT) or prostate interstitial brachytherapy (PI) and to population-based registries. Competing risk regression analyses were used to determine the cumulative risk of developing MDS. All statistical tests were two-sided. Of 10924 patients, 5119 (47%) received radiation (n = 2183 [43%] in EBRT group and n = 2936 [57%] in PI group) and 5805 (53%) were treated with RP. Overall, 31 cases of MDS were observed, with age-adjusted incidence rates no higher than in population-based registries. In univariate analyses, advancing age (hazard ratio [HR] = 1.14; 95% confidence interval [CI] = 1.09 to 1.20; P < .001) and radiotherapy exposure (HR = 3.44; 95% CI = 1.41 to 8.37; P = .007) were statistically significantly associated with development of MDS. In multivariable analyses, although advanced age (HR = 1.13; 95% CI = 1.06 to 1.19; P < .001) remained statistically associated with MDS, radiation did not, although a small non-statistically significant trend existed for PI-treated patients. MDS rates were no higher than in population-based registries. With relatively short follow-up, prostate cancer patients definitively treated with radiation did not appear to have a statistically increased risk of subsequent MDS.
    CancerSpectrum Knowledge Environment 02/2014; 106(3). DOI:10.1093/jnci/djt462 · 15.16 Impact Factor
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    ABSTRACT: Immunosuppressed patients have higher rates of cutaneous squamous cell carcinoma of the head and neck. This study reviews the effect of immune status on disease characteristics and treatment outcomes. Patients with cutaneous squamous cell carcinoma of the head and neck treated with surgery and postoperative radiotherapy between 2000 and 2011 were included. Immunosuppressed patients underwent prior organ transplantation or chemotherapy. Baseline variables were compared using χ(2) and unpaired t tests. Overall survival and disease-free survival were calculated using the Kaplan-Meier method. In this study of 59 patients, 38 (64%) were immunocompetent and 21 (36%) were immunosuppressed. Most patients had recurrent tumors (63%) and node-positive disease (61%), which were well balanced between the groups. Poorly differentiated tumors (62% vs 21%; P = .009), lymphovascular invasion (29% vs 11%; P = .08), and extracapsular extension (57% vs 41%; P = .09) were more frequent in the immunosuppressed group. Two-year disease-free survival (45% vs 62%) and 2-year overall survival (36% vs 67%) were inferior for immunosuppressed patients. Limitations include single institution, retrospective study with small sample size, and potential referral bias. Immunosuppressed patients with cutaneous squamous cell carcinoma of the head and neck more frequently present with high-risk pathologic features and inferior outcomes. Early multidisciplinary assessment and alternate management strategies merit prospective investigation. Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.
    International Journal of Radiation OncologyBiologyPhysics 02/2014; 88(2):476. DOI:10.1016/j.ijrobp.2013.11.050 · 4.18 Impact Factor
  • International Journal of Radiation OncologyBiologyPhysics 02/2014; 88(2):473. DOI:10.1016/j.ijrobp.2013.11.042 · 4.18 Impact Factor

Publication Stats

3k Citations
905.15 Total Impact Points


  • 2002–2015
    • Cleveland Clinic
      • Department of Radiation Oncology
      Cleveland, Ohio, United States
    • Lerner Research Institute
      Cleveland, Ohio, United States
  • 2011
    • Cleveland State University
      Cleveland, Ohio, United States
  • 2003–2010
    • Kaiser Permanente
      Oakland, California, United States
  • 2003–2006
    • University of Texas MD Anderson Cancer Center
      Houston, Texas, United States
  • 2004
    • University of Michigan
      Ann Arbor, Michigan, United States