Whole Lung Irradiation as a Novel Treatment for Covid-19 Pneumonia

A study published in ScienceDirect reports on a novel treatment of 25 patients with proven Covid-19 pneumonia.  All patients diagnosis was proven with an RT-PCR test, had SpO2 less than 94% on room air and a respiratory frequency of less than 24 per minute.  Patients were treated in accordance with standard Covid-19 guidelines and received a single fraction of low dose radiation therapy (LDRT) of 0.5 Gy to both lungs within 10 days of the onset of symptoms and/or 5 days of hospital admission.

LDRT was well tolerated by all patients.  A significant improvement in oxygenation was noted.  Demand for supplemental oxygen showed also a significant reduction in the post-RT period with 88% recovering completely with 10 days and being discharged from the hospital in 6 days.  Three patients deteriorated and died.

The authors concluded that based on their initial experience, LDRT is a promising treatment in a select group of patients with moderate to severe Covid-19 pneumonia and should be further investigated by a larger series.

Advantages of Hypo-fractionated versus Conventional Whole-Breast Irradiation

Shaitelman et al on a paper published by JAMA Oncol report the 6-month toxic effects and quality of life (QOL) with conventionally fractionated (CF-WBI) whole-breast irradiation (WBI) vs. hypo-fractionated WBI (HF-WBI). 

Their study included 287 women 40 years or older with stage 0 to II breast cancer for whom WBI without addition of a third field was recommended.  It was conducted between February 2011 through February 2014 and the patients were observed for a minimum of 6 months. 

The study was un-blinded randomized trial of CF-WBI (n = 149; 50.00 Gy/25 fractions + boost [10.00-14.00 Gy/5-7 fractions]) vs HF-WBI (n = 138; 42.56 Gy/16 fractions + boost [10.00-12.50 Gy/4-5 fractions]) following breast-conserving surgery.

Of 287 participants, 149 were randomized to CF-WBI and 138 to HF-WBI. Treatment arms were well matched for baseline characteristics, including FACT-B total score (HF-WBI, 120.1 vs CF-WBI, 118.8; P = .46) and individual QOL items such as somewhat or more lack of energy (HF-WBI, 38% vs CF-WBI, 39%; P = .86) and somewhat or more trouble meeting family needs (HF-WBI, 10% vs CF-WBI, 14%; P = .54). Maximum physician-reported acute dermatitis (36% vs 69%; P < .001), pruritus (54% vs 81%; P < .001), breast pain (55% vs 74%; P = .001), hyperpigmentation (9% vs 20%; P = .002), and fatigue (9% vs 17%; P = .02) during irradiation were lower in patients randomized to HF-WBI. The rate of overall grade 2 or higher acute toxic effects was less with HF-WBI than with CF-WBI (47% vs 78%; P < .001). Six months after irradiation, physicians reported less fatigue in patients randomized to HF-WBI (0% vs 6%; P = .01), and patients randomized to HF-WBI reported less lack of energy (23% vs 39%; P < .001) and less trouble meeting family needs (3% vs 9%; P = .01). Multivariable regression confirmed the superiority of HF-WBI in terms of patient-reported lack of energy and trouble meeting family needs.

 The authors concluded that treatment with HF-WBI appears to yield lower rates of acute toxic effects than CF-WBI as well as less fatigue 6 months after completing radiation therapy.

JAMA Oncol. Published online August 06, 2015. 

Incidence and Costs of Shorter Duration vs Conventional Irradiation After Breast Conserving Surgery

Bekelman et al in their study published in JAMA examined claims data from 14 commercial health care plans covering 7.4% of US adult women in 2013.   

They classified patients with early-stage breast cancer treated with lumpectomy and whole breast irradiation (WBI) from 2008 and 2013 into 2 cohorts: (1) the hypofractionation-endorsed cohort (n = 8924) that included patients aged 50 years or older without prior chemotherapy or axillary lymph node involvement and (2) the hypofractionation-permitted cohort (n = 6719) included patients younger than 50 years or those with prior chemotherapy or axillary lymph node involvement. Hypofractionated WBI (3-5 weeks of treatment) vs. conventional WBI (5-7 weeks of treatment).

Hypofractionated WBI increased from 10.6 in 2008 to 34.5% in 2013 in the hypofractionation-endorsed cohort and from 8.1% in 2008 to 21.2% in 2013 in the hypofractionation-permitted cohort. Adjusted mean total health care expenditures in the 1-year after diagnosis were $28747 for hypofractionated and $31641 for conventional WBI in the hypofractionation-endorsed cohort (difference, $2894; $1610-$4234; P < .001) and $64273 for hypofractionated and $72860 for conventional WBI in the hypofractionation-permitted cohort (difference, $8587; $5316-$12 017; P < .001). Adjusted mean total 1-year patient out-of-pocket expenses were not significantly different between hypofractionated vs. conventional WBI in either cohort.

They concluded that in spite the limitations of their study that they innumerate and discuss, hypofractionated WBI which is comparable in clinical efficacy, cosmesis, and toxicity after breast conserving surgery increased among women with early-stage breast cancer in 14 US commercial health care plans between 2008 and 2013. However, only 34.5% of patients with hypofractionation-endorsed and 21.2% with hypofractionation-permitted early-stage breast cancer received hypofractionated WBI in 2013.  Mean total health care expenditures for patients receiving hypofractionated WBI were about 10% less than for patients receiving conventional WBI.

MR–guided Focused Ultrasound a Palliative Treatment for Painful Bone Metastases

In a study published by the Journal of National Cancer Institute Hurwitz et al report on findings of a multicenter phase III trial regarding the efficacy and safety of magnetic resonance-guided focused ultrasound (MRgFUS), for palliation of pain due to bone metastases.

One hundred forty-seven patients were enrolled, with 112 and 35 randomly assigned to MRgFUS and placebo treatments, respectively. The 147 patients were treated in 17 centers in the U.S., Canada, Israel, Italy and Russia. Response rate for the primary endpoint, improvement in self-reported pain score without increase of pain medication 3 months after treatment, was 64.3% in the MRgFUS arm and 20.0% in the placebo arm (P < .001). MRgFUS was also superior to placebo at 3 months on the secondary endpoints assessing worst score Numerical Rating Scale for pain (NRS) and morphine equivalent daily dose intake (P < .001) and Brief Pain Inventory (BPI-QoL), a measure of functional interference of pain on quality of life (P < .001). The most common treatment-related adverse event was sonication pain, which occurred in 32.1% of patients. Two patients had pathological fractures, one patient had third-degree skin burn, and one patient suffered from neuropathy. Overall 60.3% of all treatment-related adverse events resolved on same day the sonication treatment was delivered.

The authors concluded that MRgFUS, a non-invasive technique, can relieve pain and improve function in most patients with skeletal metastases who have failed standard treatment such as radiation therapy.

Breast Conservation Therapy provides Better Survival for Early Stage Breast Cancer

Reseach by Agarwal S, et al published in JAMASurgery reports on an analysis of 132 149 patients who were followed between the years 1998 and 2008.  

Breast conservation therapy (lumpectomy and radiation therapy) was used to treat 70% of patients, mastectomy alone was used to treat 27% of patients, and mastectomy with radiation was used to treat 3% of patients. The 5-year breast cancer–specific survival rates of patients who underwent BCT, a mastectomy alone, or a mastectomy with radiation were 97%, 94%, and 90%, respectively (P < .001); the 10-year breast cancer–specific survival rates were 94%, 90%, and 83%, respectively (P < .001). Multivariate analysis showed that women undergoing BCT had a higher survival rate than those undergoing mastectomy alone (hazard ratio, 1.31; P < .001) or mastectomy with radiation (hazard ratio, 1.47; P < .001). 

The authors conclude that patients who underwent BCT versus mastectomy alone or mastectomy and radiation therapy for early stage invasive ductal cancer- defined as having a tumor size of 4 cm or smaller and 3 or less positive lymph nodes- have higher breast cancer specific survival.

Agarwal S, Pappas L, Neumayer M et al; Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer.  JAMA Surg. Published online January 15, 2014

doi:10.1001/jamasurg.2013.3049