No abstract

Radiation oncology has seen a rapid increase in the use of image-guided radiotherapy technology (IGRT) for prostate cancer patients over the past decade. The increase in the use of IGRT is largely driven by the fact that these technologies have been approved by the Food and Drug Administration and are now readily reimbursed by many insurance companies. Prostate cancer patients undergoing intensity modulated radiotherapy (IMRT) now have access to a wide variety of IGRTs that can cost anywhere from $500,000 or more in upfront costs, and can add anywhere from 10 to 15 thousand dollars to a course of IMRT. Some of the IGRT options include daily cone beam computed tomography, ultrasound, orthogonal x-ray units using implanted fiducial markers, implanted radiofrequency markers with the ability to localize and track prostate motion during radiotherapy (Calypso 4D), and cine magnetic resonance imaging. Although these technologies add to the cost of IMRT, there is little direct comparative effectiveness data to help patients, physicians, and policy makers decide if one technology is better than another. In our critical review, the first of its kind, we summarize the advantages, disadvantages, and the limitations of each technology. We also provide an overview of existing literature as it pertains to the comparison of existing IGRTs. Lastly, we provide insights about the need for future outcomes research that may have a significant impact on health policies as it comes to reimbursement in the modern era.

Diffuse large B-cell lymphoma (DLBCL) represents the most common subtype of non-Hodgkin lymphoma (NHL) in the United States, and two-thirds of these patients will present with advanced stage (stage III-IV) disease. Although radiation therapy (RT) alone was the first curative therapy for limited stage DLBCL, the advancement of combination chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) with the addition of the anti-CD20 antibody rituximab became the cornerstone of current management. The role of consolidative RT as part of first-line therapy in the management of patients with advanced stage DLBCL remains unclear, and represents an area of controversy with considerable differences in patterns of practice across different institutions. Emerging data now challenge the National Comprehensive Cancer Network (NCCN) guidelines, and give support to the use of consolidative RT in patients with advanced stage DLBCL. This review summarizes the major studies as reflected in our current practice and provides further insight into future directions for randomized trials which would help better define the role of consolidative RT in such a cohort.

The plan quality metric is well-correlated to the degree of anatomical similarity between a new query case and matched cases. Further work will investigate how to apply this metric to further stratify and select cases for knowledge-based planning.

8546 Background: The role of consolidative radiotherapy (RT) after a complete response (CR) to R-CHOP for stage III-IV DLBCL patients is unclear. The goal of our study is to evaluate the Emory experience when consolidative RT is delivered to initial presenting nodal and extranodal sites or bulky sites in these patients. Methods: From 01/2000 to 05/2012, 211 histologically confirmed DLBCL patients with stage III-IV disease who received R-CHOP were identified at Emory University. Patterns of failure for patients who achieved CR to R-CHOP were analyzed. Local control (LC), distant control (DC), progression free survival (PFS) and overall survival (OS) were estimated using Kaplan-Meier method and compared between patients who received R-CHOP alone versus R-CHOP plus consolidative RT using Log-rank test. Multivariate analyses were also performed using Cox proportional hazards model. Results: 163 patients had detailed treatment records. After a median 6 cycles of R-CHOP, 110 patients (67.5%) achieved CR and were entered for analysis. Fourteen patients (12.7%) received consolidative RT to a median dose of 30.6 Gy as part of initial management. With a median follow up time of 32.9 months, 43.8% of patients who received R-CHOP alone failed at the initial presenting sites with or without distant recurrence (DR), whereas isolated DR only occurred in 3.2% of these patients. Consolidative RT was associated with significantly improved LC (91.7% vs 48.8%, p<0.0001), DC (92.9% vs 71.9%, p<0.0001), PFS (85.1% vs 44.2%, p<0.0001) and OS (92.3% vs 68.5%, p<0.0001) at 5-years when compared to patients with R-CHOP alone. In addition, the in-field control rate was 100% within irradiated sites for patients who received consolidative RT. On multivariate analysis, consolidative RT and non-bulky disease were predictive of increased LC and PFS, whereas bone marrow involvement was associated with increased risk of DR and worse OS. Conclusions: 44% of patients with advanced stage DLBCL failed at initial presenting sites despite achieving a CR to R-CHOP. Incorporation of consolidative RT as part of upfront treatment in these patients was associated with improved LC and PFS.