Daniel Indelicato | University of Florida (original) (raw)

Papers by Daniel Indelicato

Pediatric Blood & Cancer, Dec 15, 2010

Materials/Methods: Forty-eight patients with nonmetastatic RMS of the hand or foot were enrolled ... more Materials/Methods: Forty-eight patients with nonmetastatic RMS of the hand or foot were enrolled on Intergroup Rhabdomyosarcoma Study Group (IRSG) III, IVP, and IV. Twenty-four patients (50%) underwent surgery without local RT, of whom 4 had complete surgical resection with negative margins and 20 had an amputation. The remaining 24 patients (50%) underwent local RT, of who 2 required RT for microscopic residual disease following prior amputation. Patients treated with RT had either biopsy/partial resection at diagnosis (11 patients) or gross total resection at diagnosis (13 patients). Median follow-up for surviving patients is 9.7 years. Results: Actuarial 10-year local control is 100%; 10-year event-free (EFS) and overall survival (OS) are 62% and 63%, respectively. Poor prognostic factors for recurrence include group III disease (p = 0.01) and lymph node involvement (p = 0.05). More patients in the RT group had alveolar histology, group III disease, and nodal involvement, as compared to the surgery group. There is no difference in 10-year EFS (57% vs. 66%) or OS (63% vs. 63%) between patients who underwent surgery or local RT. Surgery was more often performed on tumors of the feet as compared to tumors of the hands (71% vs. 29%; p = 0.01). Complete surgical resection without amputation was achieved in only 4 patients (8%) in the surgical group and 6 patients overall (13%). Regional lymph node biopsy or dissection was performed in 35 patients (73%); of these, 16 (46%) had lymph node involvement. Among relapsing patients, there are no long-term survivors. No second cancers or deaths from non-RMS causes were seen in patients who were long-term disease-free. Long-term functional outcome is excellent in all patients who did not have amputation. Conclusions: Despite having high-risk features, patients treated with local RT achieved excellent local control, although overall disease control remains suboptimal. The small number of patients who underwent a complete surgical resection without amputation highlights the difficulty of achieving a complete resection in the hand or foot. Therefore, we recommend either definitive radiation therapy or surgical resection which maintains form and function as primary local therapy rather than amputation in children with rhabdomyosarcoma of the hand and foot.

International Journal of Radiation Oncology Biology Physics, Mar 1, 2018

Radiation therapy (RT) is often used in the treatment of unresectable or recurrent aggressive fib... more Radiation therapy (RT) is often used in the treatment of unresectable or recurrent aggressive fibromatosis (also known as desmoid tumor) typically with excellent local control. Prior reports have suggested that local control in pediatric patients with aggressive fibromatosis is poor. We aimed to report a long-term single-institution experience with the radiotherapeutic treatment of these tumors with a focus on age-dependent outcomes. A total of 101 patients treated with RT for aggressive fibromatosis between 1975 and 2015 at a single institution were identified. A variety of demographic and treatment-related variables were abstracted from patients&amp;amp;amp;amp;amp;amp;amp;#39; medical records. Kaplan-Meier analyses were performed to investigate the relationship between these variables and local control. Overall survival was excellent (98% and 95% at 5 and 10 years, respectively); local control was likewise excellent (82% and 78% at 5 and 10 years, respectively). Patients aged &amp;amp;amp;amp;amp;amp;amp;lt;20 years at diagnosis had significantly worse 5-year local control than those aged &amp;amp;amp;amp;amp;amp;amp;gt;40 years at diagnosis (72% vs 97%; hazard ratio, 9.0; P = .009). Patients treated with once-daily fractionation had significantly improved 5-year local control compared with those treated with twice-daily fractionation (90% vs 73%; hazard ratio, 0.3; P = .008). Neither the presence of gross versus microscopic residual disease, initial versus recurrent presentation, number of prior surgical procedures, nor tumor size had any effect on 5-year local control. In a total of 36.6% of patients, Common Terminology Criteria for Adverse Events grade 3 or 4 toxicity developed following treatment; the frequency of toxicities was reduced in patients treated during or after 1995 (24.5%) relative to those treated prior to 1995 (51.9%, P = .02). RT for aggressive fibromatosis offers excellent local control and should remain the standard of care for patients with unresectable or recurrent disease. Younger patients have diminished local control relative to older patients, suggesting possible biological differences contributing to radioresistance in the pediatric and young adult population.

American Journal of Clinical Oncology, Dec 1, 2016

Objective: To evaluate outcomes after conservative resection and radiotherapy (RT) for soft-tissu... more Objective: To evaluate outcomes after conservative resection and radiotherapy (RT) for soft-tissue sarcoma (STS) of the distal extremity, with assessment of functional quality of life using the validated Toronto Extremity Salvage Score (TESS) questionnaire and Common Terminology Criteria for Adverse Events (CTCAE), v4.0. Methods: Thirty-three patients with STS involving the hand/wrist (N = 18) or foot/ankle (N = 15) complex received adjuvant RT with conservative resection and were evaluated for local tumor control, survival, toxicities, and preservation of objective functional ability. Eight patients were treated with preoperative RT (median dose, 50.4 Gy) and 25 with postoperative RT (median dose, 61.8 Gy). Median follow-up was 11.5 years. Functional outcomes were measured using TESS; patients with amputations were excluded from the TESS analysis. Adverse events related to gait, limb edema, skin infection, wound complication, and wound dehiscence were assessed using the CTCAE. Results: The 5-and 10-year local control rates were both 90%. The 10year cause-specific, absolute, and distant metastasis-free survival rates were 97%, 87%, and 84%, respectively. Three patients had an amputation for reasons other than local recurrence or treatment complications and underwent amputation for patient preference. One third of the subjects (11/33 patients) were able to complete the TESS questionnaire; scores ranged from 88 to 100 (mean, 98.2). CTCAEv4 acute adverse events occurred in 2 cases: 1 patient had a grade 3 skin infection and 1 had a grade 2 wound complication of dehiscence. Conclusions: For management of distal extremity STS, the combination of adjuvant RT and conservative surgery achieves excellent local control and overall survival with few adverse events. In addition, through application of the TESS survey instrument, we have demonstrated that this treatment plan achieves robust functional preservation objectively and quantifiably.

International Journal of Radiation Oncology Biology Physics, Oct 1, 2013

Materials/Methods: We prospectively enrolled 196 pediatric patients with tumors of the central ne... more Materials/Methods: We prospectively enrolled 196 pediatric patients with tumors of the central nervous system. HR-QOL was evaluated using the validated PedsQL core and tumor modules, with possible scores of 0-100 (higher scores represent better HRQOL). Parent proxy reports (PPR) were collected for children aged 2-18, and child self reports (CSR) were collected for children 6 (when able). Assessments were completed twice during treatment (beginning and end) and then yearly. Patients who progressed were taken off study. Based on parents' addresses, the following CTL socioeconomic data was collected: median family income in the child's census tract, percentage of individuals in the child's census tract who attended at least some college, and the percentage of whites in the child's census tract. These data were then dichotomized based on national medians (e.g., whether the median family income in the census tract was greater than or less than US median family income). Linear regression was used to evaluate whether any of the dichotomized census-tract level socioeconomic factors predicted for change in PedsQL tumor or core module scores from baseline to either end of treatment or one-year after treatment. Age, gender, treatment time (up-front or at progression), irradiated volume (focal or cranio-spinal), distance from our hospital, and extent of surgery (GTR, STR, or biopsy alone) were included as potential confounders. Results: Median age was 9 years (range, 1-19). Common histologies included: 54 patients (27.6%) with medulloblastoma, 36 (18.4%) with ependymoma, 32 (16.3%) with craniopharyngioma, 28 (14.3%) with germ cell tumors, and 26 (13.3%) with low-grade gliomas; 154 patients (80%) were treated up-front; the majority had focal radiation (n Z 116, 59.3%); seventy-seven (39.3%) had GTR. On multivariate analysis, patients living in a census tract with a median family income higher than the national median had a greater improvement in the PPR scores on the PedsQL core module at 1 year (relative improvement Z 18.4, p Z 0.006), but there was no association with the CSR. At no other time point did the dichotomized census-tract level variables predict change in PedsQL core or tumor module scores for either PPR or CSR. Conclusions: At 1-year after proton irradiation, higher median income in a child's census tract predicts for a positive change in parent reported HRQOL. Neither proportion white nor education level significantly

International Journal of Radiation Oncology Biology Physics, Oct 1, 2013

Purpose/Objective(s): To assess postoperative changes of cerebral glucose metabolism in craniopha... more Purpose/Objective(s): To assess postoperative changes of cerebral glucose metabolism in craniopharyngioma patients receiving proton therapy. Materials/Methods: From 2011 to 2012, 17 patients enrolled in a prospective proton therapy trial for craniopharyngioma and received longitudinal PET and MR imaging for tumor and normal tissue response. Sixteen of them underwent craniotomies before baseline FDG PET studies followed by proton therapy of 54 CGEs. One did not require surgical intervention before radiation. Patient FDG PET images were nonlinearly warped to a 3D reference template in Talairach coordinates created from images of normal subjects. Left-right asymmetry of the count per voxel in each of 63 anatomical regions and region-based statistics of activity were computed. Regional asymmetry was considered significant when its Z score exceeded two standard deviations of normal population. To exclude any potential bias in PET acquisition, 12 control children with extracranial diseases but normal cerebral PET scans were also analyzed. Results: Median age of craniopharyngioma patients at diagnosis was 13 years (range, 4-18 years). Median time from craniotomies to baseline PET studies and from PET to proton therapy was 136 days (range, 7-226 days) and 32 days (range, 20-52 days). Significantly decreased glucose uptake was most prominent in right frontal lobe, striatum, and thalamus. It occurred in 7 of 10 patients who underwent transcranial craniotomies and in 2 of 3 patients receiving endoscopic craniostomy for cyst drainage, but in none of the 4 patients who received transphenoidal surgery or no surgery. Significant asymmetry in superior frontal gyrus is related to the surgical approach (89% occurrence in right frontal, bifrontal, and interhemispheric approaches vs 0% in other approaches). Significant asymmetry in caudate nucleus, putamen, and thalamus likely resulted from mass effect, venous occlusion, and surgical damage. A large, but not significant, uptake asymmetry (averaged 9%) in the inferior occipital gyrus was observed in both craniopharyngioma and control patients. This asymmetry is possibly due to the left occipital petalia commonly seen in right handers. None of the uptake asymmetry in superior frontal lobe, striatum, and thalamus was significant in control subjects. Conclusions: Postoperative metabolic abnormalities in the right superior frontal gyrus, striatum, and thalamus were noted in craniopharyngioma patients before proton therapy. The latter two are of particular interest since they subsequently receive the tumoricidal dose or are in high dose gradient regions and play an important role in regulation of motor control, sensory function, memory, sleep, and consciousness. The association with observed clinical deficits before and after proton therapy in this population will be reported. Author Disclosure: C. Hua: None. H.M. Conklin: None. M.A. Madey: None. D.J. Indelicato: None. B.L. Shulkin: None. T.E. Merchant: None.

International Journal of Radiation Oncology Biology Physics, Oct 1, 2013

maintaining high-clinical suspicion for early-detection. Adjuvant RT may potentially improve tumo... more maintaining high-clinical suspicion for early-detection. Adjuvant RT may potentially improve tumor control following surgical resection even in the re-irradiation setting for breast angiosarcoma worthy of further investigation.

Neuro-Oncology

PURPOSE: To assess reduction of secondary radiation-induced neoplasms over the past two decades, ... more PURPOSE: To assess reduction of secondary radiation-induced neoplasms over the past two decades, focusing on children with CNS tumors who received intensity modulated radiotherapy (IMRT) or proton therapy (PT). METHODS: A total of 1044 children received radiotherapy for a primary CNS tumor at 2 institutions between 1999 and 2020, including 99 treated with IMRT and 945 treated with PT. Median age was 8.7 years old. Median follow-up was 6.0 years and included 83 and 510 patients with >5 years follow-up in the IMRT and proton cohorts, respectively. Cumulative incidence method provided estimates of secondary neoplasms encompassing benign and malignant solid tumors as well as leukemia. Multiple variables were assessed using proportional hazard regression for competing risks. RESULTS: Ten-year overall survival was 87.4%. Patients treated with IMRT were significantly older, with a median age of 10.4 vs 8.4 years old (p <0.001), but were more likely to receive craniospinal irradiation...

International Journal of Radiation Oncology*Biology*Physics, 2021

INTRODUCTION Due to the location and high dose required for disease control, pediatric chordomas ... more INTRODUCTION Due to the location and high dose required for disease control, pediatric chordomas are theoretically well-suited for treatment with proton therapy, but their low incidence limits the clinical outcome data available in the literature. We sought to report the efficacy and toxicity of proton therapy among a single-institution cohort. METHODS AND MATERIALS Between 2008 and 2019, 29 patients with a median age of 14.8 years (range, 3.8-21.8) received passive-scattered proton therapy for non-metastatic chordoma. No patient received prior irradiation. Twenty-four tumors arose in the clivus/cervical spine region and 5 in the lumbosacral spine. Twenty-six tumors demonstrated classic well-differentiated histology and 3 were dedifferentiated or not otherwise specified. Approximately half of the tumors underwent specialized testing: 14 were brachyury-positive and 10 retained INI-1. Three patients had locally recurrent tumors following surgery alone (n=2) or surgery + chemotherapy (n=1) and 17 patients had gross disease at the time of radiation. The median radiation dose was 73.8 GyRBE (range, 69-75.6). RESULTS With a median follow-up of 4.3 years (range, 1.0-10.7), the 5-year estimates of local control, progression-free survival, and overall survival rates were 85%, 82%, and 86%, respectively. No disease progression was observed beyond 3 years. Excluding 3 patients with dedifferentiated/not-otherwise-specified chordoma, the 5-year local control, progression-free survival, and overall survival rates were 92%, 92%, and 91%, respectively. Serious toxicities included 3 patients with hardware failure or related infection requiring revision surgery, 2 patients with hormone deficiency, and 2 patients with Eustachian tube dysfunction causing chronic otitis media. No patient experienced brainstem injury, myelopathy, vision loss, or hearing loss following radiation. CONCLUSION In pediatric patients with chordoma, proton therapy is associated with a low risk of serious toxicity and high efficacy, particularly in well-differentiated tumors. Complete resection may be unnecessary for local control and destabilizing operations requiring instrumentation may result in additional complications following therapy.

Journal of Clinical Oncology, 2009

e21501 Background: Primary sarcomas of the lungs and mediastinum are rare and few data are report... more e21501 Background: Primary sarcomas of the lungs and mediastinum are rare and few data are reported on treatment and results of therapy. Methods: We reviewed our experience from 1980 and 2008 including 31 patients (pts). Pts characteristics: median age 41 (19–80 y), male/female 19/12; symptoms at diagnosis: dyspnoea (42%), chest and shoulder pain (39%), cough (35%), hemophtoae (13%), discomfort (10%). 4 pts had a previous history of mediastinal radiation for Hodgkin's and non-Hodgkin's linfomas. 5 mediastinal tumours were located as follows: 2 in anterior part, 1 in posterior and 2 in the middle (sarcomas of the heart). 26 lung sarcomas presented as a singular mass in 23 cases and as a metastatic disease in 3. Results: In 20/31 cases the tumour was immediately resected (3 mediastinal masses and 17 lung sarcomas). In 8/31 cases only biopsy was possible. FNA was done in 25 pts. Neoadjuvant chemotherapy was performed in 4 cases (3 resected). Resection was complete in 11/23 case...

International journal of radiation oncology, biology, physics, Jan 29, 2018

To estimate the rate of and identify risk factors for vasculopathy after proton therapy in pediat... more To estimate the rate of and identify risk factors for vasculopathy after proton therapy in pediatric patients with central nervous system and skull base tumors. Between 2006 and 2015, 644 pediatric patients with central nervous system and skull base tumors were treated with proton therapy at a single institution. The 3 most common histologies were craniopharyngioma (n = 135), ependymoma (n = 135), and low-grade glioma (n = 131). The median age was 7.6 years (range, 0.7-21.8 years), and the median prescribed dose was 54 cobalt gray equivalent (CGE) (range, 25.2-75.6 CGE). For this analysis, vasculopathy included asymptomatic vessel narrowing identified on imaging, transient ischemic attacks, and cerebrovascular accidents. Serious vasculopathy was defined as events resulting in permanent neurologic complications or requiring revascularization surgery. Multivariate logistic regression (MVA) was used to assess predictors of toxicity. Variables examined included age, neurofibromatosis, e...

International Journal of Radiation Oncology*Biology*Physics, 2016

Materials/Methods: An observational, single-institution, retrospective study of children treated ... more Materials/Methods: An observational, single-institution, retrospective study of children treated with 3-dimensional conformal or intensitymodulated photon irradiation for posterior fossa ependymoma was performed. Clinical and demographic parameters, as well as point and incremental volumetric dose thresholds were retrospectively obtained and evaluated for association with the development of secondary thyroid malignancy or biopsy-proven benign thyroid nodule. Results: Between 10/29/1997 and 2/13/2012, 101 children, adolescents, and young adults with posterior fossa ependymoma received treatment with maximum resection and post-operative radiation therapy. The median age of the study cohort was 2.76 years (range 0.89-22.92 years). There were 41 female and 60 male patients. The total dose was 54Gy (nZ14) or 59.5Gy (nZ87) using conventional fractionation of 1.8Gy/day. Extent of resection was gross-total in 82%; multiple resections were performed in 44 patients. Overall survival at 12 years was 71.3% AE 4.8%. With a median follow-up of 11.35 years (range 4.68-17.01 years) for the survivors, the estimated 12 year incidence of papillary thyroid cancer was 2.7% AE 1.9% and biopsy-proven benign thyroid nodule 4.4% AE 3.1%. Papillary thyroid cancer was diagnosed in two patients at 6.83 and 7.14 years after irradiation. No deaths were attributed to papillary thyroid cancer. Benign thyroid nodules were diagnosed in two patients at 9.18 and 11.49 years. There was no association with dose-volume parameters and the induction of thyroid cancer or benign nodules. (see Table for dose-volume information). Maximum dose for those who developed thyroid cancer was 15.39Gy and 16.93Gy compared to those who developed benign nodules 20.75Gy and 32.25Gy. Those who developed thyroid cancer or nodules showed no pattern with low dosevolume variables yet had amongst the highest values for V10Gy (>90%ile) and V20Gy (>80%ile). Conclusion: Irradiation of children with posterior fossa ependymoma using photons risks induction of thyroid cancer from collateral irradiation. Although the risk is small and there does not appear to be an association with dose in our series, effort should be made to spare the thyroid during treatment. The use of proton therapy might be considered for vulnerable patients.

International Journal of Radiation Oncology*Biology*Physics, 2017

maximum and minimum were extracted from the SUV map and investigated as prognostic indicators for... more maximum and minimum were extracted from the SUV map and investigated as prognostic indicators for local or distant recurrence through independent t-tests. Significant weight fluctuations during EBRT occurred for 8 of the 37 patients, leading to physician initiated treatment re-planning prior to completion of EBRT treatment. Patient groups were defined for patients with (Group 1, 8 patients) and without (Group 2, 29 patients) significant weight fluctuations leading to re-planning. Kaplan-Meier (K-M) curves were generated for recurrence-free proportions where time of event was measured from the final HDR treatment date to the date of the follow-up exam when recurrence occurred or the patient was censored. These K-M curves were then compared through Cox regression. Results: At the time of follow-up visit (median of 12 months), 6 patients had local pelvic recurrence and 6 had distant recurrence. However, for the 8 patients who had significant weight fluctuation, 4 patients experienced recurrence. The minimum value from the SUV map was found to be a statistically significant indicator for recurrence through the independent t-test (pZ0.004). Cox regression found that patients in Group 2 had a hazard ratio of 0.204 (95% CI-0.051, 0.823; pZ0.025) for recurrence compared to patients in Group 1. Conclusion: The preliminary results obtained from this study suggest information collected prior to and during radiation treatment can provide indication of treatment outcomes. The minimum value of the CTV SUV map extracted from PET images prior to EBRT was identified as an indicator for recurrence. Furthermore, Cox regression demonstrated that patients with significant weight fluctuations were more likely to have recurrence. Early indicators for treatment outcome may play a vital role for the decision making process to adapt treatment plan for individual patients.

International Journal of Radiation Oncology*Biology*Physics, 2017

The long-term goal is to minimize late effects of pediatric brain tumor patients receiving proton... more The long-term goal is to minimize late effects of pediatric brain tumor patients receiving proton therapy and identify primary causes of treatment-related complications. We incorporated longitudinal functional imaging in a Phase II prospective trial of surgery and proton therapy for children with craniopharyngioma to identify affected brain regions of individual patients and associations with neuropsychological testing performance. Materials/Methods: 46 children and young adult patients underwent surgery and proton therapy (54 CGE) and protocol-specified longitudinal evaluations including cognitive testing (baseline and annual) and FDG-PET (baseline, 18mo, and 36mo). Neuropsychology evaluations included intelligence, attention and executive function, visual spatial processing and visual motor integration, fine motor skills, processing speed, and academic skills. FDG uptake in each of 63 anatomical brain regions was computed and compared to 99% prediction intervals of an age-associated normal uptake distribution to identify significantly hypometabolic regions. Results: In 16 patients treated with minimally invasive surgery (trans-sphenoidal approach), cerebral glucose distributions and neuropsychological evaluations through 3 years were normal except for 3 children who had pre-existing psychiatric conditions or severe mass effect that caused persistent hypometabolism in temporal lobes and occipital lobes. In 30 patients subjected to 1-6 craniotomies, imaging findings and performance varied. More extensive hypometabolism observed at 3 years was predominantly in frontal lobes and persistent from baseline evaluation. This occurred more frequently in patients with multiple surgeries (56% vs. 10% with 1 craniotomy). For the entire group, the percentage of below average neuropsychological performance at 3 years in evaluable patients was higher in attention (6/21 in omission errors and 4/21 in hit reaction time), fine motor skills (5/25), and verbal fluency (5/28 in retrieval fluency) and lower in visual motor integration (3/24), full scale IQ (2/27), and academic skills (2/24 in reading and 4/24 in math fluency). Although FDG PET avidity abnormalities have not yet been used to predict specific psychological deficits, two poor-performing patients showed profound imaging abnormalities. One had frontal lobe infarction and severe hypometabolism in basal ganglia and thalamus before proton therapy. The other had cerebellum, brainstem, thalamus, and insular hypometabolism on 18mo FDG PET. Conclusion: Attention, verbal fluency, and fine motor skills appeared to be the top 3 neuropsychological domains that require improvements for children with craniopharyngioma treated with surgery and proton therapy. Research is ongoing to associate endocrine dysfunction, white matter tree integrity, and metabolic imaging abnormalities with neuropsychological deficits to further explain observed results.

International Journal of Radiation Oncology*Biology*Physics, 2017

Materials/Methods: From our institution's pathology database, 143 nonmetastatic non-breast angios... more Materials/Methods: From our institution's pathology database, 143 nonmetastatic non-breast angiosarcoma RAS diagnosed between 1994-2015 were identified. Pts were excluded for <2 year (yr) latency to RAS (nZ3) and <6 month follow-up (nZ57) to form a study cohort of 83 pts. Kaplan-Meier analyses were used to calculate overall survival (OS), progressionfree survival (PFS) and local recurrence-free rate (LRFR). The log rank test was used to compare time to event distributions. Results: Median age at diagnosis of primary malignancy was 43 yrs (1-74 yrs). The most common primary histologies were lymphoma (28%), breast cancer (27%) and prostate cancer (11%). The most common sites of primary RT were non-mantle chest/breast (33%), abdomen/pelvis (27%) and mantle (18%). RT was administered to the primary malignancy between 1938-2012. Median dose was 50.4 Gy (10.8 e 88.6 Gy). Chemotherapy (CT) was delivered to 61% (nZ51). RAS diagnoses occurred at a median age of 57 yrs (27-87 yrs). Median latency between primary malignancy and RAS was 17 yrs (2-60 yrs). The most common RAS histologies were unclassified spindle cell sarcoma (39%), undifferentiated pleomorphic sarcoma (22%) and leiomyosarcoma (13%). Median tumor size was 6 cm (range 1-22 cm). RAS treatment consisted of: surgery (S) alone (33%), S+RT (27%), S+CT (22%), S+CT+RT (13%); CT+RT (4%), and CT alone (2%). No pts received RT alone. Among the 77 who underwent surgery, margins were positive in 27%, negative for 65% and unknown in 8%. Median follow-up from RAS diagnosis was 2.5 yrs (0.6-16.6 yrs). Seven pts had locally progressive disease, 13 had local recurrence (LR), 15 had distance metastasis (DM), and 13 had both. There were 15 deaths, 14 due to RAS. Two-year OS, PFS and LRFR were 85%, 47% and 65%. Median survival and time to LR were 12.9 yrs (95% CI 7.9-not reached) and 9.5 yrs (95% CI 9.5-not reached). On univariate analysis, RAS > 5 cm was associated with worse OS (96% vs. 78%, pZ0.02). There was no relationship between RAS location and outcome. In terms of treatment: patients who underwent S had better 2-yr OS than those who did not (89% vs. 25%, p<0.0001). RT had no significant association with outcomes. Use of CT was associated with worse OS (72% vs. 95%, pZ0.0004) and PFS (28% vs. 60%, pZ0.0001), however, these groups were not balanced for prognostic factors. Conclusion: In this large, single institution cohort of RAS, excluding breast angiosarcoma, outcomes were generally poor with half of patients progressing within 2 years. Definitive resection was associated with better outcome, but favorable effects of RT or CT were not apparent. Further study is needed into improved therapeutic options for this heterogeneous patient population.

International Journal of Radiation Oncology*Biology*Physics, 2017

associated with OS. The actuarial rate of grade !3 necrosis was 7.0% (95% CI Z 3.3-15.0), with me... more associated with OS. The actuarial rate of grade !3 necrosis was 7.0% (95% CI Z 3.3-15.0), with median time of onset of 8.6 months after RT2. Conclusion: Re-irradiation for relapsed pediatric ependymoma results in long-term survival for many patients. Patients with 1q gain are at risk of distant failure. RT2 CSI changes the pattern of failure in patients with local-only failure after RT1, with no distant failures observed. Novel biomarkers to select patients who benefit most from CSI are needed.

Journal of Clinical Oncology, 2008

21507 Background: The management of isolated local recurrence of soft tissue sarcoma is therapeut... more 21507 Background: The management of isolated local recurrence of soft tissue sarcoma is therapeutically complex, and functional conservative management would be preferable to radical or amputative ...

Pediatric blood & cancer, Jan 24, 2017

International, multidisciplinary care of children with central nervous system (CNS) tumors presen... more International, multidisciplinary care of children with central nervous system (CNS) tumors presents unique challenges. The aim of this study is to report patient outcomes of U.K. children referred for proton therapy to a North American facility. From 2008 to 2016, 166 U.K. children with approved CNS tumors were treated with proton therapy at a single academic medical center in the United States. Median age was 7 years (range, 1-19). Median follow-up was 2.6 years. The 3-year actuarial overall survival (OS) and local control (LC) rates were 96% and 91%, respectively, for the overall group, 92% and 85% for the ependymoma subgroup (n = 57), 95% and 88% for the low-grade glioma subgroup (n = 54), and 100% and 100%, respectively, for the craniopharyngioma subgroup (n = 45). Cyst expansion was observed in 13 patients, including one case resulting in visual impairment. Serious side effects included new-onset seizures in three patients (1.8%), symptomatic vasculopathy in three patients (1.8...

International Journal of Radiation Oncology*Biology*Physics, 2016

For young children treated with radiation therapy, daily anesthesia required for immobilization i... more For young children treated with radiation therapy, daily anesthesia required for immobilization increases the cost of treatment and adds potential long-term morbidity. Through education and therapeutic play interventions, a certified child life specialist (CCLS) reduces the need for daily anesthesia, particularly in children aged 3 to 8 years. The CCLS intervention results in significant health care cost savings to the payer and eliminates unnecessary Purpose: To analyze the effectiveness of a certified child life specialist (CCLS) in reducing the frequency of daily anesthesia at our institution, and to quantify the potential health care payer cost savings of CCLS utilization in the United States. Methods and Materials: From 2006 to 2014, 738 children (aged 21 years) were treated with radiation therapy at our institution. We retrospectively analyzed the frequency of daily anesthesia before and after hiring a CCLS in 2011 after excluding patients aged 0 to 2 and >12 years. In the analyzed cohort of 425 patients the median age was 7.6 years (range, 3-12.9 years). For the pre-CCLS period the overall median age was 7.5 years; for the post-CCLS period the median age was 7.7 years. An average 6-week course of pediatric anesthesia for radiation therapy costs 50,000inchargestothepayer.TheaverageannualcosttoemployoneCCLSisapproximately50,000 in charges to the payer. The average annual cost to employ one CCLS is approximately 50,000inchargestothepayer.TheaverageannualcosttoemployoneCCLSisapproximately50,000. Results: Before employing a CCLS, 69 of 121 children (57%) aged 3 to 12 years required daily anesthesia, including 33 of 53 children (62.3%) aged 5 to 8 years. After employing a CCLS, 124 of 304 children (40.8%) aged 3 to 12 years required daily anesthesia, including only 34 of 118 children (28.8%) aged 5 to 8 years (P<.0001). With a >16% absolute reduction in anesthesia use after employment of a CCLS, the health care payer cost savings was approaching $50,000 per 6 children aged 3 to 12 years treated annually with radiation therapy in our institution. This reduction

Pediatric Blood & Cancer, Dec 15, 2010

International Journal of Radiation Oncology Biology Physics, Mar 1, 2018

American Journal of Clinical Oncology, Dec 1, 2016

International Journal of Radiation Oncology Biology Physics, Oct 1, 2013

Neuro-Oncology

International Journal of Radiation Oncology*Biology*Physics, 2021

Journal of Clinical Oncology, 2009

International journal of radiation oncology, biology, physics, Jan 29, 2018

International Journal of Radiation Oncology*Biology*Physics, 2016

International Journal of Radiation Oncology*Biology*Physics, 2017

Journal of Clinical Oncology, 2008

Pediatric blood & cancer, Jan 24, 2017

International Journal of Radiation Oncology*Biology*Physics, 2016