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BACKGROUND: The long-term risk of cardiovascular outcomes from either stereotactic body radiation therapy (SBRT) or three-dimensional conformal radiation therapy (3DCRT) plus intensity-modulated radiation therapy (IMRT) to treat early stage non-small cell lung cancer (NSCLC) is largely unknown. As continued adoption of SBRT accelerates, it is important to delineate unforeseen cardiovascular risks associated with treatment. RESEARCH QUESTION: Does the long-term risk of cardiovascular outcomes for patients with early stage NSCLC treated with either SBRT or 3DCRT plus IMRT differ by tumor laterality? STUDY DESIGN AND METHODS: Data from the Surveillance, Epidemiology, and End Results registry linked to Medicare was analyzed to identify a sample of 3,256 patients (1,506 treated with SBRT and 1,750 treated with 3DCRT plus IMRT) with node-negative stage I or IIA NSCLC. Cardiovascular events were identified using diagnosis codes, and outcomes were compared between left- and right-sided tumors. We assumed that tumor laterality was random and that the radiation field for left-sided tumors likely would result in greater dose to cardiac tissues. Cox regression models were fit to quantify the association of laterality on outcomes. RESULTS: Patients were followed up for a median of 2 years. Those treated with SBRT showed no difference in hazard of any cardiovascular outcomes by tumor laterality, including the cardiovascular composite (hazard ratio [HR] comparing left- vs right-sided tumors, 0.98; 95% CI, 0.84-1.15). In contrast, patients treated with 3DCRT plus IMRT showed a greater risk of congestive heart failure (HR, 1.23; 95% CI, 1.01-1.48) and percutaneous coronary artery intervention (HR, 2.24; 95% CI, 1.12-4.47). INTERPRETATION: Patients with left- vs right-sided early stage NSCLC showed similar rates of cardiovascular events when treated with SBRT. However, these patients also showed higher rates of select cardiac events when they were treated with 3DCRT plus IMRT. This study provides evidence that SBRT may provide a safer option over 3DCRT plus IMRT for patients with left-sided early stage NSCLC and underscores the need for long-term follow-up for patients treated with radiation therapy.

To describe outcomes and compare the effectiveness of stereotactic body radiotherapy (SBRT) versus 3-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) in patients with stage IIA lymph node-negative (N0) non-small cell lung cancer (NSCLC) tumors5 cm.We used the SEER-Medicare database (2005-2015) to identify patients65 years with stage IIA (AJCC TNM7) N0 NSCLC5 cm tumors who were treated with SBRT, IMRT, and 3DCRT. We used propensity score methods with inverse probability weighting to compare lung cancer-specific survival (LCSS), overall survival (OS), and toxicity.Of 584 patients, 88 (15%), 140 (24%), and 356 (61%) underwent SBRT, IMRT, and 3DCRT, respectively. The SBRT group was older (P = .004), had more comorbidities (P = .02), smaller tumors (P = .03), and more adenocarcinomas (P.0001). We found a trend towards higher median unadjusted OS with SBRT compared to IMRT and 3DCRT (19 vs. 13 and 14 months, respectively, P = .37). In our propensity score-adjusted analyses, SBRT was significantly associated with better OS and LCSS compared to IMRT (HRFor patients with NSCLC tumors5 cm, SBRT trends towards fewer toxicities and improved survival compared to other forms of radiotherapy. Our findings support SBRT as an appropriate treatment strategy for older patients with larger inoperable NSCLC tumors.

Treatment planning for malignant pleural mesothelioma is a challenging task due to the relatively large size of the target and the need to spare critical organs that overlap with or are within the target volume. We aimed to develop a knowledge-based model using RapidPlan (RP) for patients with 2 intact lungs.Data from 57 patients treated with volumetric modulated arc therapy were chosen for training the dose estimation model at a single dose level. The prescription dose was 50.4 Gy in 1.8 Gy fractions. The model was validated on 23 new patients by comparing the clinical plan to the RP. Time taken to plan the RP was compared with that for the clinical plan.For similar target coverage and plan inhomogeneity, RP significantly improved the sparing of the contralateral lung, heart, stomach, esophagus, and ipsilateral kidney. On average, the contralateral lung V5 Gy and V10 Gy were reduced by 13.9% (P.001) and 7.9% (P.001), respectively. The mean heart dose was reduced by 5 Gy (P.001) and V30 Gy by 9.1% (P.001). Mean dose to the stomach and esophagus were both reduced by 5 Gy (P.001), and the ipsilateral kidney V18 Gy by 4.1% (P.001). Mean total lung dose was reduced by 0.8 Gy with RP, which enabled an increase in prescription dose by 1 fraction Absolute volume of ipsilateral lung was adequately spared by both techniques, while sparing of all other organs, namely the cord, liver, and bowel, was not compromised with RP. Time taken with RP was 20 minutes, 45 seconds versus at least 4 hours for an experienced treatment planner.The RP model for malignant pleural mesothelioma showed improved sparing of critical organs with a reduced treatment planning time and increased prescription dose.

Radiation therapy (RT) plays an important role in the curative treatment of a variety of thoracic malignancies. However, delivery of tumoricidal doses with conventional photon-based RT to thoracic tumors often presents unique challenges. Extraneous dose deposited along the entrance and exit paths of the photon beam increases the likelihood of significant acute and delayed toxicities in cardiac, pulmonary, and gastrointestinal structures. Furthermore, safe dose-escalation, delivery of concomitant systemic therapy, or reirradiation of a recurrent disease are frequently not feasible with photon RT. In contrast, protons have distinct physical properties that allow them to deposit a high irradiation dose in the target, while leaving a negligible exit dose in the adjacent organs at risk. Proton beam therapy (PBT), therefore, can reduce toxicities with similar antitumor effect or allow for dose escalation and enhanced antitumor effect with the same or even lower risk of adverse events, thus potentially improving the therapeutic ratio of the treatment. For thoracic malignancies, this favorable dose distribution can translate to decreases in treatment-related morbidities, provide more durable disease control, and potentially prolong survival. This review examines the evolving role of PBT in the treatment of thoracic malignancies and evaluates the data supporting its use.

Introduction The standard-of-care therapy for extensive-stage SCLC has recently changed with the results of two large randomized trials revealing improved survival with the addition of immunotherapy to first-line platinum or etoposide chemotherapy. This has led to a lack of clarity around the role of consolidative thoracic radiation and prophylactic cranial irradiation in the setting of chemoimmunotherapy. Methods The American Radium Society Appropriate Use Criteria are evidence-based guidelines for specific clinical conditions that are reviewed by a multidisciplinary expert panel. The guidelines include a review and analysis of current evidence with the application of consensus methodology (modified Delphi) to rate the appropriateness of treatments recommended by the panel for extensive-stage SCLC. Results Current evidence supports either prophylactic cranial irradiation or surveillance with magnetic resonance imaging every 3 months for patients without evidence of brain metastases. Patients with brain metastases should receive whole-brain radiation with a recommended dose of 30 Gy in 10 fractions. Consolidative thoracic radiation can be considered in selected cases with the recommended dose ranging from 30 to 54 Gy; this recommendation was driven by expert opinion owing to the limited strength of evidence, as clinical trials addressing this question remain ongoing. Conclusions Radiation therapy remains an integral component in the treatment paradigm for ES-SCLC.

Introduction Combined modality therapy with concurrent chemotherapy and radiation has long been the standard of care for limited-stage SCLC (LS-SCLC). However, there is controversy over best combined modality practices for LS-SCLC. To address these controversies, the American Radium Society (ARS) Thoracic Appropriate Use Criteria (AUC) Committee have developed updated consensus guidelines for the treatment of LS-SCLC. Methods The ARS AUC are evidence-based guidelines for specific clinical conditions that are reviewed by a multidisciplinary expert panel. The guidelines include a review and analysis of current evidence with application of consensus methodology (modified Delphi) to rate the appropriateness of treatments recommended by the panel for LS-SCLC. Agreement or consensus was defined as less than or equal to 3 rating points from the panel median. The consensus ratings and recommendations were then vetted by the ARS Executive Committee and subject to public comment before finalization. Results The ARS Thoracic AUC committee developed multiple consensus recommendations for LS-SCLC. There was strong consensus that patients with unresectable LS-SCLC should receive concurrent chemotherapy with radiation delivered either once or twice daily. For medically inoperable T1-T2N0 LS-SCLC, either concurrent chemoradiation or stereotactic body radiation followed by adjuvant chemotherapy is a reasonable treatment option. The panel continues to recommend whole-brain prophylactic cranial irradiation after response to chemoradiation for LS-SCLC. There was panel agreement that prophylactic cranial irradiation with hippocampal avoidance and programmed cell death protein-1/programmed death-ligand 1–directed immune therapy should not be routinely administered outside the context of clinical trials at this time. Conclusions The ARS Thoracic AUC Committee provide consensus recommendations for LS-SCLC that aim to provide a groundwork for multidisciplinary care and clinical trials.

Purpose The Open Payments transparency program publishes data on industry-physician payments, in part to discourage relationships considered inappropriate including gifts, meals, and speaker’s bureau fees. We evaluated trends in physician-level payments to test whether implementation of Open Payments resulted in fewer industry–radiation oncologist (RO) interactions or shifted interactions toward those considered more appropriate compared with medical oncologists (MOs) and other hospital-based physicians (HBPs). Methods and Materials We performed a retrospective, population-based cohort study of practicing US ROs versus MOs and HBPs in 2014 matched to general (nonresearch) payments between 2014 and 2018. Trends in payments were analyzed and reported by nature of payment. Values of payments to ROs from the top 10 companies were identified. Results From 2014 to 2018, 3379 (90.3%) ROs accepted 106,930 payments totaling $40.8 million. The per-physician number and value of payments was lower in radiation oncology than in medical oncology and higher than HBPs. The proportion of ROs accepting payments increased from 61.8% in 2014 to 64.2% in 2018; the proportion of MOs accepting payments decreased from 78.7% to 77.7%; and the proportion of HBPs decreased from 40.8% to 37.5%, respectively. The annual per-physician value and number of payments accepted by ROs and MOs increased. Payments in entertainment, meals, travel and lodging, and gifts increased among ROs and remained stable or decreased among MOs and HBPs. Consulting payments increased across all groups. Top RO payors produced novel cancer therapeutics, hydrogel spacers, radiation treatment machines, and opioids. Conclusions Industry payments to ROs have become more common since OP’s inception, while becoming less common for MOs and HBPs. Payments to ROs and MOs have become more frequent and of modestly increasing value compared with other HBPs, for whom the value is decreasing. No large changes in the nature of relationships were seen in ROs. Increased engagement with financial conflicts of interest is needed in radiation oncology.

Nivolumab has been demonstrated to be effective for the treatment of unresectable hepatocellular carcinoma (HCC). While many patients may additionally benefit from radiation therapy (RT), the toxicity of combination nivolumab and RT is unknown. Patients who underwent liver-directed RT prior to or concurrent with nivolumab for HCC at our institution were reviewed. Toxicity was assessed by Common Terminology Criteria for Adverse Effects v5.0 criteria until disease progression, change in systemic therapy, additional liver-targeted locoregional therapy (LRT), or death. Prevalence ratios (PR) were compared for patients undergoing prior and concurrent RT. Childs-Turcotte-Pugh (CTP) and Albumin-Bilirubin (ALBI) scores at 1-, 3-, and 6-months were compared with baseline. We identified 55 patients with median follow-up 6.0 months; 34 (62%) received prior and 21 (38%) received concurrent RT. Grade 3+ toxicity occurred in 8 patients (17%). Grade 3+ toxicities did not differ between prior and concurrent RT cohorts on the univariable analysis (PR 1.91; 95% CI 0.42, 8.59) but were higher in the prior RT cohort on the multivariable analysis (PR 5.42; 95% CI 1.42, 20.67; p = 0.013). Mean CTP scores increased from baseline (6.33) at 1 month (7.04; 95% CI 6.80, 7.27) and 3 months (6.81; 95% CI 6.43, 7.19) and thereafter normalized; mean ALBI scores increased from baseline (− 1.93) at 1 month (− 1.75; 95% CI − 1.84, − 1.66) with no difference thereafter. Combination RT and nivolumab is generally safe in the management of unresectable HCC with a low rate of serious adverse events. Prospective trials investigating the efficacy of combination nivolumab and RT are warranted.

Purpose Recent randomized studies have suggested improvements in progression-free and overall survival with the addition of stereotactic body radiation therapy (SBRT, also known as SABR) in patients with oligometastatic non-small cell lung cancer. Given the novelty and complexity of incorporating SBRT in the oligometastatic setting, the multidisciplinary American Radium Society Lung Cancer Panel was assigned to create appropriate use criteria on SBRT as part of consolidative local therapy for patients with oligometastatic and oligoprogressive non-small cell lung cancer. Methods and Materials A review of the current literature was conducted from January 1, 2008, to December 25, 2020, using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to systematically search the PubMed database to retrieve a comprehensive set of relevant articles. Results Based on representation in existing randomized trials, the panel defined the term “oligometastasis” as ≤3 metastatic deposits (not including the primary tumor) in the previously untreated setting or after first-line systemic therapy after the initial diagnosis. “Oligoprogression” also referred to ≤3 discrete areas of progression in the setting of prior or ongoing receipt of systemic therapy. In all appropriate patients, the panel strongly recommends enrollment in a clinical trial whenever available. For oligometastatic disease, administering first-line systemic therapy followed by consolidative radiation therapy (to all sites plus the primary/nodal disease) is preferred over up-front radiation therapy. Owing to a dearth of data, the panel recommended that consolidative radiation therapy be considered on a case-by-case basis for 4 to 5 sites of oligometastatic disease, driver mutation-positive oligometastatic disease without progression on up-front targeted therapy, and oligoprogressive cases. Conclusions Although SBRT/SABR appears to be both safe and effective in treating patients with limited metastatic sites of disease, many clinical circumstances require individualized management and strong multidisciplinary discussion on account of the limited existing data.

Background Excellent outcomes and high rates of pathologic complete response (pCR) have been reported in patients with operable esophageal carcinoma using 41.4 Gy of radiation with concurrent carboplatin and paclitaxel. With pCR rates similar to studies using higher doses, it remains unclear whether doses greater than 41.4 Gy result in improved outcomes. This study aims to compare pCR rates and oncologic outcomes in patients treated with neoadjuvant chemoradiation to 50.4 Gy vs 41.4 Gy. Methods We reviewed the charts of patients with operable esophageal carcinoma who were treated with neoadjuvant chemoradiation followed by oncologic resection. Our primary endpoint was the pCR rate. Secondary endpoints were overall survival, progression-free survival (PFS), and toxicity. Results We identified 43 patients meeting inclusion criteria. Nineteen patients were treated with 41.4 Gy and 24 were treated with 50.4 Gy. Cohorts were well-matched, except for a significantly higher percentage of patients with adenocarcinoma (AC) (89.5% vs 54.2%, p = 0.02), usage of intensity-modulated radiation therapy (IMRT) (100% vs 47.6%; p = 0.002), and usage of carboplatin, plus paclitaxel (100% vs 75%; p = 0.003) in the 41.4 Gy group. The pCR rate for the cohort was 44.2%. No differences in the pCR rate (41.7% vs 47.4%), three-year overall survival (OS) (73.7% vs 77.5%), or three-year PFS (52.8% vs 43.7%) were observed. Late toxicity rates also did not vary significantly (p = 0.2). No grade 4 or 5 events were observed. Conclusion In this small series, there were no differences in the pCR rate, PFS, or OS between those treated with 50.4 Gy and 41.4 Gy. Larger, multi-institutional series are needed to validate these findings.

Aim: Volumetric modulated arc therapy (VMAT) has been utilized to plan and treat multiple cranial lesion metastases using a single isocenter due to its ability to provide steep dose gradients around targets as well as low doses to critical structures. VMAT treatment is delivered in a much shorter time compared to using a single isocenter for the treatment of each lesion. However, there is a need to develop methods to reduce the treatment planning time for these cases while also standardizing the plan quality. In this work we demonstrate the use of RapidPlan, which is a knowledge-based treatment (KBP) planning software to plan multiple cranial SRS cases. Methods: 66 patient plans with 125 lesions (range 1-4, median 1) were used to train a model. In addition, the model was validated using 10 cases that were previously treated and chosen randomly. The clinical plans were compared to plans generated by RapidPlan for target coverage and critical organ dose. Results: Coverage to the target volume, gradient index (GI), conformity index (CI) and minimum dose to the target showed no significant difference between the original clinical plan versus the plan generated by KBP. A comparison of doses to the critical organs namely the brainstem, brain, chiasm, eyes, optic nerves and lenses showed no significant difference. Target dose homogeneity was slightly better with the clinical plan, however this difference was also statistically insignificant. Conclusion: This work demonstrates that KBP can be trained and efficiently utilized to help decrease the treatment planning time while standardizing and optimizing treatment plan quality.

Lung cancer is the leading cause of cancer death in the USA and timely treatment plays a major role in the prognosis. Peer-to-peer insurance prior authorizations are believed to represent a major cause of treatment delays. However, the effect of peer-to-peer prior authorizations on radiotherapy treatment delays in lung cancer remains unknown. We reviewed departmental treatment records between September 2015 and 2018 for patients who received radiation therapy (RT) with curative intent for lung cancer. Our primary endpoint was delay in RT initiation; delay in RT simulation served as a secondary endpoint. Univariate and multivariate logistic regressions were used to estimate the effect of peer-to-peer reviews on treatment delays of at least 7 days. Two hundred and seventy patients were included. The median treatment delay was 6.5 days for those requiring peer-to-peer review versus 1 day for those who did not (Wilcoxon rank-sum test, p = 0.002). Univariate logistic regression found peer-to-peer review to be strongly correlated with a delay in start of treatment (OR = 3.58, p = 0.002) and simulation (OR = 9.24, p

With increasing use of radiation for hepatocellular carcinoma (HCC) through transarterial radioembolization (TARE) and stereotactic body radiation therapy (SBRT), there is concern for increased radiation-related complications when using SBRT after TARE. This study compares safety of SBRT after segmental TARE versus transarterial chemoembolization (TACE).A retrospective review identified patients receiving SBRT after TACE or TARE for HCC from 2011 to 2017. TARE was delivered subselectively to individual segments using yttrium-90 with Theraspheres. Patients were assessed over time for Child-Turcott-Pugh (CTP)/albumin-bilirubin (ALBI) scores, and Common Terminology Criteria for Adverse Events version 4.0 grade ≥3 events. Linear mixed models were used to examine the trend of CTP and ALBI over time and compare groups. Secondary endpoints were objective response rate via modified Response Evaluation Criteria in Solid Tumors (RECIST), local control, and overall survival.Ninety-nine patients met criteria with median follow-up of 9.8 months (range, 0.9-47): 31 had SBRT after segmental TARE and 68 patients post-TACE. The groups were well balanced with regard to etiology of HCC, baseline CTP and ALBI scores, and SBRT dose, but there were significant differences in baseline Eastern Cooperative Oncology Group performance status, Barcelona Clinic Liver Cancer staging, and median follow-up. There was a significant increase in post-SBRT CTP and ALBI scores (P.0001) for both groups. However, there was no significant difference in rise in CTP (P = .11) or ALBI score (P = .82) over time between SBRT post-TACE versus post-segmental TARE. There was no significant increase in ≥grade 3 toxicity postsegmental TARE. There was also no significant difference in local controls (P = 1.0) and overall survival (P = .26) between cohorts, but objective response rate was worse post-TARE.SBRT after segmental TARE with Theraspheres appears to have acceptable tolerability and is effective compared with SBRT after TACE. Longer follow-up with larger numbers is needed to verify these data.

Introduction Detailed guidelines regarding the use of radiation therapy for malignant pleural mesothelioma (MPM) are currently lacking because of the rarity of the disease, the wide spectrum of clinical presentations, and the paucity of high-level data on individual treatment approaches. Methods In March 2017, a multidisciplinary meeting of mesothelioma experts was cosponsored by the U.S. National Cancer Institute, International Association for the Study of Lung Cancer Research, and Mesothelioma Applied Research Foundation. Among the outcomes of this conference was the foundation of detailed, multidisciplinary consensus guidelines. Results Here we present consensus recommendations on the use of radiation therapy for MPM in three discrete scenarios: (1) hemithoracic radiation therapy to be used before or after extrapleural pneumonectomy; (2) hemithoracic radiation to be used as an adjuvant to lung-sparing procedures (i.e., without pneumonectomy); and (3) palliative radiation therapy for focal symptoms caused by the disease. We discuss appropriate simulation techniques, treatment volumes, dose fractionation regimens, and normal tissue constraints. We also assess the role of particle beam therapy, specifically, proton beam therapy, for MPM. Conclusion The recommendations provided in this consensus statement should serve as important guidelines for developing future clinical trials of treatment approaches for MPM.

Objectives Patients with hepatocellular carcinoma (HCC) and gross vascular invasion (GVI) have poor outcomes with systemic therapy such as sorafenib. Both external beam radiation therapy (EBRT) and transarterial radioembolization (TARE) have been utilized for this patient population. We sought to compare outcomes using dual modality radiation (EBRT+TARE) versus EBRT alone in patients with HCC and GVI. Materials and methods Between 2011 and 2017, 45 patients with HCC and GVI were treated with EBRT±TARE at our institution. Progression-free survival (PFS) and overall survival (OS) were assessed and compared using Kaplan-Meier method and log-rank test. Univariable and multivariable Cox proportional hazards regression was used to assess the impact of the variables stage, etiology of cirrhosis, Child-Pugh (CP) score, and Karnofsky Performance Score (KPS) on PFS and OS. Results Patient characteristics were well-balanced except for KPS (80 vs. 90) and CP score. Median OS for patients receiving EBRT+TARE was 263 days (95% confidence interval [CI]: 167, -) versus 193 days (95% CI: 51, 262) for EBRT alone (P=0.049). However, this did not hold up on MVA. When EBRT and TARE were delivered within 2 months as planned (n=12), median PFS was 218 days (95% CI: 44, -) for dual modality radiation versus 63 days (95% CI: 38, 137) for EBRT alone (P=0.048). When EBRT and TARE were delivered within 6 months, the difference in PFS was no longer seen (P=NS), because some patients received TARE as a salvage therapy. Conclusions Dual modality radiation with EBRT and TARE may be associated with improved OS in patients with HCC and GVI. Dual modality radiation may be associated with improved PFS in patients with HCC and GVI compared with EBRT alone when EBRT and TARE are delivered within 2 months of each other as part of a planned dual modality treatment strategy. However, since this is a retrospective study with inherent selection bias, these findings need further validation in a prospective clinical trial for patients with HCC and GVI.

Glioma susceptibility is inversely related to a history of allergies and atopy. Lung allergies are associated with 30% lower glioma susceptibility, compared to no lung allergies. Asthma and eczema also reduce the chance of glioma. However, the effect of allergy on glioma survival is not well characterized. Because of the allergy-glioma inverse relationship we examined the association of allergy with glioma survival in The Cancer Genome Atlas (TCGA).We evaluated the association between allergy and overall survival in TCGA Glioma (LGG) dataset. In order to have a sample of sufficient size to analyze, we classified as allergic any patient who answered yes to any of the manifestations of allergy that were queried.We analyzed data from 526 patients with glioma. History of allergy conferred a survival advantage on glioma patients, when stratified by tumor histologic grade (p = 0.049). Because allergy confers a favorable prognosis, we performed Cox regression. The effect of allergy on survival was significant (p = 0.025, HR 0.525, 95% CI 0.299-0.924), independent of the effect of chromosome 1p (p 0.001, HR 93.4, 95% CI 16-546) and 19q (p = 0.801, HR 1.2, 95% CI 0.23-6.9) codeletion or TP53 mutation (p = 0.015, HR 2.7, 95% CI 1.2-5.9), unrelated to TERT expression (p = 0.365, HR 1.1, 95% CI 0.89-1.4) or ATRX mutation (p = 0.904, HR 1.04, 95% CI 0.51-2.14), independent of tumor grade (grade 2 versus grade 3, p = 0.004, HR 2.2, 95% CI 1.3-3.8), not independent of histology (oligodendroglioma and oligoastrocytoma, NOS versus astrocytoma, p = 0.08, HR 0.62, 95% CI 0.36-1.1). Diminished RNA expression of three loci, having reproducible genetic associations with allergic disease risk, are significantly associated with increased survival in glioma: FOSL2, APOBR, and NCF4. Diminished NCF4 copy number is significantly associated with reduced survival (D).Our finding of the improved prognosis that allergy confers on glioma increases the potential importance of understanding the allergy-glioma inverse association. If the mechanism could be more clearly elucidated, new, more effective treatments and preventive measures may be developed. Further studies are warranted.

BACKGROUND: Although surgical resection is considered the standard of care for early-stage non-small cell lung cancer, radiotherapy [stereotactic body radiation therapy (SBRT)] has been proposed as a minimally invasive treatment alternative. Studies have not examined differences in quality of life (QoL) between surgery and radiotherapy, despite important implications for patient and provider decision making. METHODS: The Surveillance, Epidemiology, and End Results Medicare Health Outcomes Survey (1998–2014) was used to assess changes in physical QoL score [Physical Component Summary (PCS)] and mental health QoL score [Mental Component Summary (MCS)] from baseline (prior to cancer diagnosis) to follow-up after treatment with surgery only or radiotherapy only. QoL was measured using the 36-item Short Form Health Survey (SF-36) until 2006, when it was replaced by the Veterans RAND 12-Item Health Survey (VR-12). RESULTS: Data from 184 patients (28 SBRT, 156 surgery) was included. There was a significant decline in PCS score from baseline to follow-up (surgery: −4.81; 95% CI: −6.31, −3.30; P

Background: Infiltrating lobular carcinoma (ILC) is the second most common histologicaI subtype of breast cancer, accounting for 10% of all cases. ILC has a characteristic genomic profile. ILC shows a high frequency of cadherin 1 (CDH1) mutations, along with loss of phosphatase and tensin homolog (PTEN), activation of alpha serine/threonine kinase (AKT), and mutations in T-box transcription factor (TBX3) and forkhead box protein A1 (FOXA1). We suspected that another gene, von Willebrand factor (VWF), might also be part of the profile, since coagulation tests reveal significant differences in patients with breast cancer. Materials and Methods: For newly-diagnosed breast cancer, the association between VWF and histology in the GDC Breast Cancer dataset in The Cancer Genome Atlas (TCGA) was evaluated. The following were used to access and analyze the data: Genomic Data Commons Data Portal (https://portal.gdc.cancer.gov/); Xena browser (https://xenabrowser.net); cBioportal (http://cbioportal.org); Oncomine (https://oncomine.org); and Prediction Analysis of Microarray 50 (PAM50). Results: Patients with ILC had higher VWF RNA expression than patients with infiltrating ductal carcinoma and other histology. The difference of expression was present to the same degree in both pre-menopausal and post-menopausal patients. Nine alterations in VWF and PTEN were significantly co-occurrent. Considering all histologies in 843 samples, Tukey’s honest significant difference post hoc test showed that VWF RNA expression of the normal subtype was significantly greater than that of the other subtypes (p

PURPOSE/OBJECTIVE(S) Chest wall rib fractures are frequent complications after thoracic stereotactic body radiation therapy (SBRT). While well described for lung SBRT, limited data exists on the frequency and predictors for chest wall toxicity with SBRT to the liver for primary or metastatic lesions. We aimed to characterize the clinical, demographic and dosimetric factors of rib fractures. MATERIALS/METHODS A chart review identified 283 patients (204 male and 79 female) who received liver SBRT from 2014-2019. Univariate logistic regression models were used to identify demographic, clinical, and dosimetric factors associated with the development of rib fractures post liver SBRT. All statistical tests were two-sided and the null hypothesis was rejected for P 30 (P = 0.36) were not associated with the development of rib fractures. CONCLUSION Rib fractures after liver SBRT are a rare event and were observed in 8% of patients. Clinicians should continue to utilize well-established dose constraints and minimize radiation dose delivery to the chest wall.

There has not been an assessment of the Holman Research Pathway (HRP) in radiation oncology (RO) in nearly 10 years. In this study, we sought to review the demographic characteristics, research productivity during and after residency, job placements, and National Institutes of Health (NIH) grant funding of RO residents who completed the HRP in the modern era.We created a comprehensive database of RO residents who completed the HRP between 2010 and 2019. Using a variety of data sources, we obtained demographic information, first-author manuscripts published in residency, and first- and last-author manuscripts published in the first 30 months after residency for each resident. In addition, we identified the first and current job and NIH grant funding for each resident.Ninety-seven RO residents who graduated from 50 medical schools and 25 residency programs were included. The majority were male (82.5%), had a PhD (92.8%), and identified as white (64.9%). Collectively, these residents published 212 first-author, PubMed-searchable manuscripts during residency (mean: 2.2) and 142 first- or last-author, PubMed-searchable manuscripts in the first 30 months after completion of residency (mean: 1.5). The number of first-author publications authored by HRP graduates during residency was highly correlated (r = 0.62; P.01) with the number of first- and last-author publications they authored during the first 30 months after completing residency. Ninety-six of the 97 residents (99.0%) were employed in full-time clinical positions after completing residency. Seventy-six HRP residents (78.4%) obtained an academic position as their first job after residency, only 4 of whom have since left academia, and 20 (20.6%) obtained a nonacademic position. Of the 75 HRP graduates currently employed in an academic position, 39 (52.0%) have their own laboratories. Twenty-three of the 96 HRP residents (24.0%) who secured employment in full-time clinical positions after residency switched jobs over the study period. Lastly, 33 of the 97 HRP residents (34.0%) have thus far received 47 extramural NIH research grants, 15 of which were R-01 grants.Over the past decade, the HRP has proven successful in training a new cohort of physician investigators in RO. Although productive, HRP residents have had relatively homogenous sex, educational, and racial backgrounds. Ensuring sufficient representation of residents from a variety of backgrounds in the HRP in the future will be crucial.

Introduction Patients with hepatocellular carcinoma (HCC) involving the inferior vena cava (IVC) and/or right atrium (RA) often experience debilitating symptoms, including lower extremity edema, dyspnea on exertion, shortness of breath at rest, chest pain, and ascites, that impact quality of life. The efficacy of external beam radiation therapy (EBRT) in palliating these symptoms is unclear. Thus, we sought to assess the effectiveness of EBRT in the palliation of symptoms and treatment outcomes in this patient population. Materials and methods All patients with HCC that compressed or invaded the IVC, received EBRT, and had a two-month follow-up visit to assess clinical response at our institution between 2010 and 2018 were analyzed. Patient demographics and clinical features were retrieved from the electronic medical record. Local control, local progression-free survival, and overall survival (OS) were measured from the last day of EBRT and calculated using the Kaplan-Meier method. Results Twenty-six patients with invasion or compression of the IVC were identified, 11 of whom (42%) had involvement of the RA. The median follow-up was 3.6 months. Five patients (19%) were treated with stereotactic body radiation therapy (SBRT) (all with five fractions) and 21 patients (81%) were treated with fractionated radiation therapy (range 10-16 fractions), both to a median dose of 3,000 cGy (range 2500-4000 cGy for SBRT, 2500-3750 cGy for fractionated radiation therapy). Significant proportions of patients experienced symptomatic relief from peripheral edema (54%), dyspnea on exertion (57%), shortness of breath (83%), chest pain (67%), and ascites (25%) after receiving EBRT. Additionally, they experienced few toxicities, with zero experiencing grade three or higher toxicities. One-year and two-year local control rates were 11.5% and 7.7%, respectively, and the median local progression-free survival was 4.8 months. One-year and two-year OS rates were 38.4% and 38.4%, respectively. Conclusions Our results suggest that EBRT should be considered as a potential treatment option for patients with HCC invading or compressing the IVC with or without involvement of the RA. EBRT was very well-tolerated and effectively palliated a variety of symptoms in patients with advanced disease.

IMPORTANCE: Given the potential for undue influence of industry-physician payments on oncology care, it is important to understand how a national transparency program may be associated with financial interactions between industry and medical oncologists. OBJECTIVE: To identify trends in industry payments to medical oncologists from 2014 to 2019 and determine if the implementation of the Open Payments program is associated with changes in the frequency or value of payments or any shift in the nature of industry-oncologist financial interactions. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, population-based, observational cohort study analyzed Open Payments reports of industry payments made in 2014 to 2019 to a cohort of licensed medical oncologists practicing in the US in 2014, using data from the National Plan and Provider Enumeration System. EXPOSURES: Receipt of an industry payment from January 1, 2014, to December 31, 2019. MAIN OUTCOMES AND MEASURES: General industry payments to medical oncologists, including the proportion receiving payments, total annual value and number of payments, and average annual trends over time, by aggregate value and by nature-of-payment category. Trends over time were analyzed using linear regression and generalized estimating equations. RESULTS: In 2014 to 2019, there were 15 585 medical oncologists who received a total of 2.2 million industry payments with a total value of $509 million. The absolute number of oncologists receiving payments decreased from 10 498 in 2014 to 8918 in 2019 (−15.1%). The annual per-physician payment value decreased among those receiving less than $10 000 in aggregate by −3.2% yearly (95% CI, −4.1% to −2.3%; P

Malignant pleural mesothelioma is an aggressive tumor where the ability to control the primary tumor (local control) presents a significant challenge. External beam radiation has the potential to improve local control when following established safe and effective protocols. Radiation is primarily used as adjuvant treatment after extrapleural pneumonectomy or pleurectomy/decortication and as palliative treatment in some cases. The target volume for radiotherapy of malignant pleural mesothelioma can be quite extensive and thus toxicity is its chief limitation.

The Code of Federal Regulations is a single-source repository of all rules and regulations promulgated by federal departments and agencies. In Title 10, Chapter 1, Part 35, Subpart D, §§35.100 to 35.290 detail regulations for the use of unsealed by product material not requiring a written directive (ie, diagnostic radiopharmaceuticals), and in Subpart E, §§35.300 to 35.396 detail regulations for the use of unsealed by product material requiring a written directive (ie, therapeutic radionuclides). Currently proposed changes for both Subparts D and E could have profound effects on patient care, public safety, and the practice of nuclear medicine, diagnostic radiology, and radiation oncology. This article details those proposed changes and actions under way to prevent promulgation of proposals that could negatively affect patient care and public safety.

Objective Although the prognostic role of human papilloma virus (HPV) status in oropharyngeal head and neck squamous cell carcinoma (SCC) is well established, growing evidence shows that there may be a prognostic role for HPV status in hypopharyngeal SCC. The objective of this study was to determine the prognostic role of HPV status in hypopharyngeal SCC. Methods We performed a retrospective, population‐based analysis of 1934 adult patients with HNSCC diagnosed between 2010‐2016 and treated with a combination of surgery and/or radiotherapy, with or without chemotherapy, and a subset of 641 patients with hypopharyngeal SCC and known HPV status included in the Surveillance, Epidemiology, and End Results (SEER) Head and Neck with HPV Status Database. Patient data were used to determine the adjusted 2‐year cancer‐specific survival (CSS) and overall survival (OS) for the entire cohort and the specific subgroup of hypopharyngeal cancer patients with known HPV status. Results Of the 1934 hypopharynx SCC cases, HPV status was unknown in 1294 (66.9%), and 167 (8.6%) were HPV positive; among hypopharynx cases with known HPV status, 21.6% were HPV positive. In models adjusting for sex, age, race/ethnicity, marital status and stage, patients with HPV‐positive hypopharyngeal tumors had improved CSS compared with patients with HPV‐negative tumors (CSS: HR: .57, 95% CI = .38 to .86, P = .008; OS: HR: .49, 95% CI = .34 to .71, P =, We performed a population‐based analysis to determine the adjusted 2‐year cancer‐specific survival and overall survival of 641 patients with hypopharyngeal SCC and known HPV status included in the Surveillance, Epidemiology, and End Results Head and Neck with HPV Status Database. In models adjusting for sex, age, race/ethnicity, marital status and stage, patients with HPV‐positive hypopharyngeal tumors had improved CSS compared with patients with HPV‐negative tumors (CSS: HR: .57, 95% CI=.38 to .86, P=.008; OS: HR: .49, 95% CI=.34 to .71, P=

Purpose/Objective(s): The COVID-19 pandemic is impacting all aspects of life and changing the practice of medicine. Multiple recommendations exist on how radiation oncology practices should deal with this crisis, but little information is available on what actually happens when the COVID-19 surge arrives. New York City experienced the first surge of COVID-19 in the United States and is now the epicenter of the global pandemic. This study reviews the impact of COVID-19 on a hospital system in New York on aspects of medicine, nursing, radiation therapy, and administration. Materials/Methods: A retrospective review was conducted of the department of radiation oncology in a single health system in New York from 3/1/20 to 4/1/20. Collaboration was obtained from physicians, nursing, radiation therapy, and administration to recall their policies and impact on specific duties. A timeline was reconstructed to chronicle significant events. Numbers were obtained for patients on treatment, treatments breaks, and COVID-19 infections amongst staff and patients. Results The COVID-19 surge had a tremendous impact on the health system including cessation of all of surgeries, including oncologic surgery, as well as transfer of all inpatient oncology services to makeshift outpatient facilities. Radiation Oncology made aggressive efforts to reduce patients on treatment to protect patients and staff as well reallocate staff and space for more acute clinical needs. Patients on-beam were reduced by 27% from 172 to 125 by 4/1/20. Almost all visits were changed to telemedicine within 2 weeks. Infection rates and quarantine were quite low amongst staff and patients. The majority of residents were deployed into COVID-19 clinical settings. Conclusion While “planning for the worst”, our health system was able to make necessary changes to still function at a reduced capacity. Our experience will give other departments a concrete experience to help them make their own policies and manage expectations., While there is a lot of discussion of what might happen to a radiation oncology practice during the COVID -19 pandemic, there is very limited information on what actually happens. This article records the experiences of academic radiation oncology practice in New York City where the initial surge of COVID-19 took place in the United States. It details effects of patients, physicians, nurses, and radiation therapists.

Purpose Several sentinel phase III randomized trials have recently been published challenging traditional radiation therapy (RT) practices for small cell lung cancer (SCLC). This American Society for Radiation Oncology guideline reviews the evidence for thoracic RT and prophylactic cranial irradiation (PCI) for both limited-stage (LS) and extensive-stage (ES) SCLC. Methods The American Society for Radiation Oncology convened a task force to address 4 key questions focused on indications, dose fractionation, techniques and timing of thoracic RT for LS-SCLC, the role of stereotactic body radiation therapy (SBRT) compared with conventional RT in stage I or II node negative SCLC, PCI for LS-SCLC and ES-SCLC, and thoracic consolidation for ES-SCLC. Recommendations were based on a systematic literature review and created using a consensus-building methodology and system for grading evidence quality and recommendation strength. Results The task force strongly recommends definitive thoracic RT administered once or twice daily early in the course of treatment for LS-SCLC. Adjuvant RT is conditionally recommended in surgically resected patients with positive margins or nodal metastases. Involved field RT delivered using conformal advanced treatment modalities to postchemotherapy volumes is also strongly recommended. For patients with stage I or II node negative disease, SBRT or conventional fractionation is strongly recommended, and chemotherapy should be delivered before or after SBRT. In LS-SCLC, PCI is strongly recommended for stage II or III patients who responded to chemoradiation, conditionally not recommended for stage I patients, and should be a shared decision for patients at higher risk of neurocognitive toxicities. In ES-SCLC, radiation oncologist consultation for consideration of PCI versus magnetic resonance surveillance is strongly recommended. Lastly, the use of thoracic RT is strongly recommended in select patients with ES-SCLC after chemotherapy treatment, including a conditional recommendation in those responding to chemotherapy and immunotherapy. Conclusions RT plays a vital role in both LS-SCLC and ES-SCLC. These guidelines inform best clinical practices for local therapy in SCLC.

Objectives The chromosome 1p/19q co-deletion is a favorable prognostic factor in patients with low grade glioma. In the current analysis, we examined MycBP expression in low grade glioma. MycBP lies on chromosome 1p. Patients and methods We evaluated the association between MycBP and overall survival in the TCGA Lower Grade Glioma (LGG) dataset in TCGA (The Cancer Genome Atlas). Results Loss of MycBP copy number segment expression coincides with co-deletion of 1 P. The deleterious effect of MycBP on survival is significant (p = 0.00006306, hazard ratio 2.02, 95% CI 1.4–2.9). Patients with astrocytoma have the poorest survival of low grade glioma patients. MycBP mRNA is significantly overexpressed in astrocytomas when compared to normal brain (2.156 fold change, p = 0.0000488). Conclusion Our report that Chromosome 1 P co-deletion may confer better survival in patients with lower grade glioma in part because of loss of MycBP corroborates other studies of the importance of MycBP in glioma development. Further work with microRNAs may lead to new treatments.

Background Two large studies suggest that risk is not increased. But other studies have found increased risk of Alzheimer's disease and impaired cognition. Objective To determine whether androgen deprivation therapy increases the risk of impaired cognition or Alzheimer's disease in men with prostate cancer. Methods We used data from MedWatch, the Food and Drug Administration (FDA) Safety Information and Adverse Event Reporting Program. Machine-readable data from MedWatch, including adverse drug reaction reports from manufacturers, are part of a public database. We used the online tool OpenVigil 2.1 to query the database. OpenVigil calculates proportional reporting ratios (PRRs) from adverse drug reaction reports to determine whether the combination of drug and adverse event are related. For example, PRR = 2 indicates that the adverse reaction is two times more frequent in users of the drug than in the general population. Results We analyzed adverse event reporting data for these androgen-deprivation drugs: The luteinizing hormone releasing hormone (LHRH) agonists leuprolide, goserelin triptorelin, histrelin; the anti-androgens flutamide, nilutamide, enzalutamide, and bicalutamide; the LHRH antagonist degarelix; the CYP17 inhibitor abiraterone; the anti-fungal ketoconazole, which is also an anti-androgen administered to men with advanced prostate cancer. Conclusion Our analysis of FDA MedWatch adverse event data reports does not support the idea that androgen deprivation therapy per se is associated with Alzheimer's disease or cognitive dysfunction. Perhaps the prostate cancer itself, or the stress it imposes on the man who has it, may be detrimental to mood and intellect, increasing susceptibility to Alzheimer's disease and cognitive disorder.

Stereotactic body radiation therapy (SBRT) is an effective and well tolerated treatment for early stage non-small cell lung cancer (NSCLC). The high doses used in thoracic SBRT can sometimes cause adverse effects ranging from mild fatigue and transient esophagitis to fatal events such as pneumonitis or hemorrhage. Efforts continue to expand in both the utility of this technique as well as our understanding of the mechanisms of the adverse effects it can cause. In this review, we discuss the current literature regarding the potential mechanisms, dosimetric constraints and toxicities associated with SBRT alone and in conjunction with definitive chemoradiotherapy and immunotherapy. As the use of SBRT expands to these spheres, we examine the available recommendations for mitigating potential associated treatment related toxicities.

INTRODUCTION: The optimal radiation dose in locally advanced non-small cell lung cancer (NSCLC) is not known for patients who receive sequential chemoradiation or definitive radiation only. Our objective was to determine whether there is a benefit to radiation dose escalation for these patients. METHODS: Patients included in our retrospective analysis received radiation treatment for NSCLC between 2004 and 2013, did not have surgery, and received a dose ≥50.0 Grays (Gy). Patients who received concurrent chemoradiation were excluded from the analysis, leaving 336 patients included. The primary outcomes were overall survival, local failure, and distant failure. RESULTS: On multivariate analysis, after adjusting for age, Karnofsky performance status, gross tumor volume, and treatment modality, patients treated with radiation dose >66 Gy had significantly improved overall survival compared to those treated with 66 Gy had a significantly decreased risk of local failure compared to those treated with 66 Gy versus

Background: Venous thromboembolism is a common complication in patients with glioma. The clotting factor von Willebrand factor (VWF) is a highly adhesive procoagulant molecule that mediates platelet adhesion to endothelial and subendothelial surfaces. In the current analysis, we examined The Cancer Genome Atlas (TCGA) data to assess the effect of VWF gene expression on prognosis in patients with lower grade gliomas (LGGs). Methods: For newly diagnosed gliomas, we evaluated the association between VWF and overall survival in the genomic data commons TCGA LGG dataset in TCGA. Survival data of the glioma subgroup were extracted for analysis and generation of Kaplan–Meier curves for overall survival. Results: Lower grade gliomas with less VWF gene expression had significantly better survival than those with more VWF gene expression (hazard ratio 0.64, 95% confidence interval 0.44–0.92, P = 0.015 log rank test). The effect of VWF gene expression on survival was even more evident when the sample was analyzed as three groups (P = 0.00019). IDH1, TP53, and ATRX mutations are present in 40% or more adult LGGs. Conclusion: The deleterious prognostic effect of VWF expression in LGGs is not surprising, given its role in other cancers. Therefore, VWF gene expression may be a clinically important risk marker in LGG.

PURPOSE/OBJECTIVE(S) We aimed to examine how the rise of open access (OA) journals in biomedicine has impacted resident research in radiation oncology. MATERIALS/METHODS We built a comprehensive database of first-author, PubMed-searchable articles published by US radiation oncology residents who graduated between 2015 and 2019. We then classified each journal in which these manuscripts appeared as either OA or non-OA, and obtained the current article processing charge (APC) for every publication that appeared in an OA journal. Lastly, we performed a secondary analysis to identify the factors associated with publishing an article in an OA journal. RESULTS The US radiation oncology residents in this study published 2,637 first-author, PubMed-searchable manuscripts, 555 (21.0%) of which appeared in 138 OA journals. The number of publications in OA journals increased from 0.47 per resident for the class of 2015 to 0.79 per resident for the class of 2019. Likewise, the number of publications in OA journals with a 2019 impact factor of zero increased from 0.14 per resident for the class of 2015 to 0.43 per resident for the class of 2019. Publications in OA journals garnered fewer citations than those in non-OA journals (8.9 versus 14.9, P < 0.01). 90.6% of OA journals levy an APC for original research reports (median $1,896), which is positively correlated with their 2019 impact factor (r = 0.63, P < 0.01). Aggregate APCs totaled $900,319.21 for all US radiation oncology residency programs and appeared to increase over the study period. CONCLUSION The number of first-author, PubMed-searchable manuscripts published by graduating US radiation oncology residents in OA journals rose significantly over the study period. US radiation oncology residency programs appear to be investing increasing and significant sums of money to publish the work of their residents in these journals. A more substantive discussion about the proper role of OA journals in resident research is needed.

BACKGROUND Exposure of the brain to ionizing radiation might promote the development of Alzheimer's disease (AD). OBJECTIVE Analysis of AD death rates versus radon background radiation and total background radiation in U.S. states. METHODS Total background, radon background, cosmic and terrestrial background radiation measurements are from Assessment of Variations in Radiation Exposure in the United States and Report No. 160 - Ionizing Radiation Exposure of the Population of the United States. 2013 AD death rates by U.S. state are from the Alzheimer's Association. RESULTS Radon background ionizing radiation was significantly correlated with AD death rate in 50 states and the District of Columbia (r = 0.467, p = 0.001). Total background ionizing radiation was also significantly correlated with AD death rate in 50 states and the District of Columbia (r = 0.452, p = 0.001). Multivariate linear regression weighted by state population demonstrated that AD death rate was significantly correlated with radon background (β= 0.169, p

Introduction Higher target conformity and better sparing of organs at risk with modern radiotherapy (RT) may result in higher tumor control and less toxicity. In this study, we compare our institutional multimodality therapy experience of adjuvant chemotherapy and hemithoracic intensity-modulated pleural RT (IMPRINT) with previously used adjuvant conventional RT (CONV) in patients with malignant pleural mesothelioma (MPM) treated with lung-sparing pleurectomy/decortication (P/D). Methods We analyzed 209 patients who underwent P/D and adjuvant RT (131 who received CONV and 78 who received IMPRINT) for MPM between 1974 and 2015. The primary end point was overall survival (OS). The Kaplan-Meier method and Cox proportional hazards model were used to calculate OS; competing risks analysis was performed for local failure-free survival and progression-free survival. Univariate analysis and multivariate analysis were performed with relevant clinical and treatment factors. Results The median age was 64 years, and 80% of the patients were male. Patients receiving IMPRINT had significantly higher rates of the epithelial histological type, advanced pathological stage, and chemotherapy treatment. OS was significantly higher after IMPRINT (median 20.2 versus 12.3 months, p = 0.001). Higher Karnofsky performance score, epithelioid histological type, macroscopically complete resection, and use of chemotherapy/IMPRINT were found to be significant factors for longer OS in multivariate analysis. No significant predictive factors were identified for local failure or progression. Grade 2 or higher esophagitis developed in fewer patients after IMPRINT than after CONV (23% versus 47%). Conclusions Trimodality therapy including adjuvant hemithoracic IMPRINT, chemotherapy, and P/D is associated with promising OS rates and decreased toxicity in patients with MPM. Dose constraints should be applied vigilantly to minimize serious adverse events.

Introduction Locoregional recurrence after resection of non–small-cell lung cancer (NSCLC) is common. We examined outcomes after definitive radiotherapy (RT) to identify prognostic factors for survival and further recurrence. Patients and Methods We reviewed 152 patients who received RT for locoregional recurrent (LR)-NSCLC, and analyzed subsequent overall survival (OS), locoregional failure (LRF), distant metastasis (DM), and any disease progression (LRF and DM). Results Two- and 5-year OS were 49% and 28%, respectively. Two- and 5-year LRF, DM, and any disease progression rates were 40% and 45%, 33% and 37%, and 53% and 57%, respectively. Performance status and intensity-modulated RT (IMRT) were independently associated with OS, as was RT dose ≥ 60 Gy. Stage, chemotherapy at recurrence, and surgery to recurrence interval were not independently associated with outcome. Chemotherapy at initial presentation, adenocarcinoma histology, and male sex were independently associated with higher rates of DM. Conclusion To our knowledge, this is the largest reported series of LR-NSCLC treated with definitive RT. Survival appears comparable to or greater than that of primary NSCLC. Subsequent LRF is more common than distant failure. Established prognostic factors for primary NSCLC, such as chemotherapy and stage, were not clearly prognostic in this analysis. IMRT and higher RT doses were associated with improved survival, though IMRT patients were also treated more recently. These data support definitive-intent RT with optimal dose and technique in such patients.

The objectives of this study were to analyze rates of radiation therapy (RT) utilization for malignant pleural mesothelioma (MPM) and evaluate the association between RT and overall survival (OS). The National Cancer Data Base (NCDB) was queried to identify patients with non-metastatic MPM diagnosed between 2004 and 2013. RT was defined as receipt of 40-65Gy of external beam radiation therapy to the chest wall, lungs, or pleura. Multivariable logistic regression was performed to identify predictors of RT receipt. OS was estimated using the Kaplan-Meier method. Propensity score matching was performed to verify the effect of RT on OS. Among 14,090 MPM patients, 3.6% received RT. Younger age, lower co-morbidity score, private insurance, surgical resection, and receipt of chemotherapy were associated with increased RT utilization. Patients who received RT had higher crude 2 and 5-year OS rates (33.9 and 12.6%, respectively) compared to patients who did not (19.5 and 5.3%, respectively; p

Detailed guidelines pertaining to radiological assessment of malignant pleural mesothelioma are currently lacking due to the rarity of the disease, complex morphology, propensity to invade multiple planes simultaneously, and lack of specific recommendations within the radiology community about assessment, reporting, and follow-up. In March 2017, a multidisciplinary meeting of mesothelioma experts was co-sponsored by the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and the Mesothelioma Applied Research Foundation. One of the outcomes of this conference was the foundation of detailed, multidisciplinary consensus imaging and management guidelines. Here, we present the recommendations for radiologic assessment of malignant pleural mesothelioma in the setting of clinical trial enrollment. We discuss optimization of imaging parameters across modalities, standardized reporting, and response assessment within clinical trials.