Abstract Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and dose-limiting side effect of neurotoxic chemotherapy for breast cancer patients. CIPN develops within weeks or months after chemotherapy is initiated and affects 30-40% of breast cancer patients. As a result of severe CIPN, about 8% of breast cancer patients require their chemotherapy dose to be reduced or discontinued, which could detrimentally impact breast cancer related outcomes. Acupuncture is a Traditional Chinese Medicine technique that involves inserting filiform stainless steel needles into pre-defined points on the skin. Previous clinical trials suggest that acupuncture may be an effective treatment to reduce CIPN symptoms with minimal interactions with chemotherapy. Methods: We are conducting a pilot, randomized, standard care and placebo controlled clinical trial (N = 60) assessing the effects of acupuncture to prevent chemotherapy dose reduction due to CIPN. Breast cancer patients receiving taxane based chemotherapy in the neoadjuvant or adjuvant setting will be screened for development of Grade 2 CIPN by completing a weekly Functional Assessment of Cancer Therapy-Neurotoxicity (FACT-Ntx) questionnaire. If patients develop Grade 2 CIPN during chemotherapy they will be randomized to one of three groups: real acupuncture (N = 20), sham acupuncture (N = 20) or standard of care (N = 20). Patients and investigators will be blinded to the treatment assignments. All patients will complete FACT-Ntx and Neuropathy Pain Scale questionnaires weekly. Patients in the real or sham acupuncture groups will receive weekly real or sham acupuncture treatments. Use of pain medications and acupuncture-related adverse events will be self recorded daily in patient diaries. We will explore changes in serum nerve growth factor and other neurotrophic factors such: as brain-derived neurotrophic factor, neurotrophin-3, insulin-like growth factors, and vascular endothelial growth factor. Blood (4 ml) will be drawn before each real or sham acupuncture treatment, at the end of chemotherapy, and at a 4 week follow up visit. Statistics: We expect that acupuncture will significantly decrease the number of patients who require dose reduction during a course of chemotherapy, and increase chemotherapy cumulative relative dose intensity. When a sample size in each cohort is 20, a three group Chi-square test with a 0.05 Type I error will have an adequate 85% power to distinguish between these groups of patients when the proportions are characterized by effect size, of 0.187. We expect the following proportions of patients who would require dose reduction in the acupuncture, sham acupuncture and standard care arms to be 0.05, 0.2, and 0.5, respectively. Statistical analysis will be conducted on-intent-to treat basis. Our specific aims are: to determine the effect of acupuncture on chemotherapy dose reduction, to determine the effect of acupuncture on CIPN during chemotherapy and to explore the mechanisms of acupuncture in treating CIPN. Nine subjects have been consented for screening and one has been randomized. Recruitment is ongoing. Please contact rkirk@umm.edu if interested in the trial. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-1-09.
Stereotactic irradiation of extracranial targets is an emerging treatment approach in clinical radiotherapy. Unlike the situation for intracranial stereotactic irradiation or radiosurgery, hypofractionated stereotactic radiotherapy of extracranial targets is complicated by internal organ motion and difficulty regarding patient rigid fixation. Therefore, for clinical implementation of extracranial stereotactic radiotherapy, treatment planning strategies to reduce normal lung toxicity have to be analyzed and properly addressed. For eligible patients who satisfied our clinical criteria for hypofractionated stereotactic radiotherapy, three CT scans, one under normal breathing (free breathing) and two under inspiration and expiration breath holding respectively, were obtained while the patients were immobilized in an FDA-approved stereotactic body frame. The scans for breath holding covered the tumor region only. Planning target volumes (PTVs) were determined by the assessment of tumor volumes based on the fusion between three CT simulation with the aid of the body frame. Confirmation of organ motion was conducted using MR cine scans. The setup accuracy of the body frame was previously studied for an extracranial site using four CT scans - one pretreatment (simulation) and three during-treatment (approximately 2 weeks apart) CT scans. The setup uncertainty was further reduced by pre-treatment CT scanning in the treatment room using a CT scanner on a sliding gantry for localization. For each specific target geometry, various treatment planning strategies using arcs, co-planar and non-coplanar, conformal and IMRT techniques were explored and compared. Treatment planning evaluation was based on dose conformality in terms of the treatment volume ratio, normal tissue toxicity in terms of the lung volume receiving 20 Gy (V20), and dose uniformity. An IRB approved dose escalation protocol was derived using a hypofractionated scheme for the treatment of primary non-small cell lung cancer and lung metastasis (maximum lesion size of 5 cm) with 10, 12, or 14 Gy per fraction for 4 treatments. Our results were based on analysis of various treatment plans for six patients comparing arcs, co-planar and non-coplanar, conformal and IMRT techniques. The optimal treatment technique depended on the geometry of the target. It was found that for smaller and well rounded planning target volumes (PTV) (less than 3.0 cm diameter), multiple arc beams using circular cones offered the best dose conformity and greatly reduced normal tissue toxicity (V20 ? 5%). For larger and irregular shaped PTVs, multi-field (5–9) conformal radiotherapy was found to be equivalent to IMRT. For all of the cases, 90% of the isodose surfaces encompassed the PTV. The maximum doses to contralateral lung were less than 12.5% of the prescribed dose. The volume of the ipsilateral lung receiving the prescribed dose was less than 2.0%. It is clinically feasible to deliver much higher than conventional radiation doses to a well defined target volume without violating normal tissue toxicity requirements. For small lesions, the optimal planning technique was multiple arc beams using circular cones. For larger lesions, conformal radiotherapy was dosimetrically as good as IMRT. Indeed, the clinical use of IMRT for small lung lesions should be used cautiously as the advantage of the intensity modulated distribution could be compromised by respiratory motion
Unintentional intraarterial injection of radiotracers may cause artifacts leading to difficulties in accurately interpreting PET/CT images. We report a case of a 73-y-old man with a history of metastatic colon cancer who underwent a PET/CT scan for restaging. In the PET scan, there was intense and diffuse distribution of (18)F-FDG in his left forearm and hand. This is a classic sign of an accidental intraarterial injection of (18)F-FDG in the antecubital region. Similar phenomena after inadvertent intraarterial injection of other radiotracers are reviewed. The associated risk factors, preventive measures, and radiation dose to the arm are discussed.
