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Loyola University Medical Center

Oncology Program2011 Annual Report

The Cardinal Bernardin Cancer Center is located on the east side of

the campus and faces First Avenue. Parking is available in a parking

lot in front of the building and valet parking is available at the entrance.

A coffee bar is located just inside the building on the first floor. Named

in honor of the late Archbishop of Chicago Joseph Cardinal Bernardin,

the cancer center was the first free-standing facility in Illinois dedicated

to cancer research, diagnosis, treatment and prevention. Loyola’s cancer

center contains all outpatient cancer care along with extensive research

laboratories, offices and educational space. Many of the multidisciplinary

clinics within the cancer center provide a one-visit, one-team approach,

providing patients with a diagnosis and treatment plan in the same

day. Patients can see their physician, have lab work done, undergo

chemotherapy and have cancer care-related prescriptions filled,

among many other services in the building.

Annual Report 2011 • 1Oncology Program 2011

Table of Contents

Introduction

Our MissionChairman’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

MembersOncology Committee Members & Specialty . . . . . . . . . . . . . . . . . . . . 3

Oncology ServicesServices Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Primary Site TableStatistical Breakdown of 2011 Cases . . . . . . . . . . . . . . . . . . . . . . . 5

Data AnalysisNarrative Results of 2011 Cases . . . . . . . . . . . . . . . . . . . . . . . . 6

Cancer IncidenceCancer Incidence by Sex & Site Comparison with National & State . . . . . . . . . . . . 9

Melanoma Cancer Study with Survival ComparisonA Long Term Patient Care Evaluation of Melanoma Cancer Cases . . . . . . . . . . . . 10Low Dose Rate to High Dose Rate Brachytherapy Transition: Maintaining Outcomes /

Decreasing Staff Dose / Transforming the Care of Soft Tissue SarcomaPatient Care Evaluation of Soft Tissue Sarcoma with Survival Comparison . . . . . . . . . 30

GlossaryDefinitions & References . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2 • Loyola University Health System Oncology Program 2011

Mission Statement

Trinity Health Mission StatementWe serve in Trinity Health, in the spirit of the Gospel, to heal body, mind and spirit to improve the health of our communities, and to steward the resources entrusted to us .

Loyola University Health System is committed to excellence in patient care and the education of health professionals . We believe that our Catholic heritage and Jesuit traditions of ethical behavior, academic distinction and scientific research lead to new knowledge and advance our healing mission in the communities we serve . We believe that thoughtful stewardship, learning and constant reflection on experience improve all we do as we strive to provide the highest-quality health care .

We believe in God’s presence in all our work . Through our care, concern, respect and cooperation, we demonstrate this belief to our patients and families, our students and each other . To fulfill our mission, we foster an environment that encourages innovations, embraces diversity, respects life and values human dignity . We are committed to going beyond the treatment of disease . We also treat the human spirit .

Brand PromiseThe people of Loyola promise patients that we go beyond the illness to treat the whole person .

Message from the ChairmanThe year 2011 brought combined improvements to the wide array of cancer services available to patients of Loyola University Medical Center, American College of Surgeons Accredited Oncology Program . It is with great pleasure to offer my congratulations to the entire cancer team from administration to all clinical and volunteer staff in this institution to providing high quality cancer care to our patients, meeting and exceeding the standards set by our Cancer Program, and on being named a recipient of the 2011 Commission on Cancer (CoC) Outstanding Achievement Award .

This report provides an overview of the Program’s organization of services and highlights a statistical summary in a narrative, tabular and graphic form of all cancer cases diagnosed and treated at Loyola University Medical Center .

Through our commitment and determination the accomplishments of the Oncology program is wholly dependent upon the tireless efforts of a team of caring professionals, without whom we could not strive to reach our goal in providing oncology service of highest caliber .

In March 2011, Loyola opened the largest academic medical center outpatient facility in the Chicago suburbs . The 100,000-square-foot Loyola Center for Health at Burr Ridge features state-of-the-art technology and patient-centered specialty care and immediate care convenience of access to primary care, rehabilitation, specialty care and immediate care-and a café, in one inviting, comfortable location .

In April 2011, Loyola broke ground on the health sciences campus for the new Mercella Niehoff School of Nursing building and Center for Collaborative Learning . The facility is designed to provide students of nursing, medicine and health sciences with opportunities to learn in a team-based environment to improve patient care . Also, families will benefit from a redesigned and renovated Emergency Department and a new inpatient oncology floor designed to promote healing and patient empowerment, focusing on comfort, privacy, respect and compassion .

In November, 2011, the first phase of the oncology inpatient renovation project was implemented to include a significant upgrade to the sixth floor Bone Marrow Transplant Unit . This Phase I project is anticipated to take approximately twelve months to complete . Improvements will include enhanced patient and staff flow on the unit, private patient rooms, and dedicated space and amenities for family members .


Membership List

The Cancer Committee membership is multidisciplinary, representing physicians from the diagnostic and treatment specialties and non-physicians from administrative and supportive services . The following list of Committee members in 2011 reflects the multidisciplinary nature of the Cancer Committee:

MEMBER SPECIALTY

Gerard V. Aranha, M.D. Surgical Oncology Oncology Program Committee Chairman Professor and Chief

Laura Michaelis, M.D. Hematology/OncologyOncology Program Committee Co-Chairman

Constantine Godellas, M.D. Surgical OncologyOncology Program Cancer Liaison Physician

Davide Bova, M.D. Diagnostic Radiology

Barbara Buturusis, MSN Director Cancer Service Line

Mary Maryland, MSN, RN ACS Nurse Navigator for Illinois

Violeta Dimovic, CTR Manager, Oncology Data Management

Kathleen Fujiu, RN, BA, BSN, MBA, OCN Nurse Manager 6 West, Coordinator

Sister Fran Glowinski Associate Chaplain, Pastoral Care

Kathy Grego, RHIT, CTR Oncology Data Management, Coordinator

Ewa Jaraczewska Manager, Orthopedic Surgery & Rehabilitation

John Lee, MD Pathology

Robert Maurer, Jr. FACHE Director, Oncology Business Support

Tess McCoo Radiation Therapy

Edward Melian, M.D. Radiation Therapy

Stephanie Mills, RHIT Oncology Data Management

Laura Morrell Social Work, Cancer Center, Coordinator

Janet Palutsis, RN Assistant Manager Clinic A Cancer Center

Ceil Petrowsky, RN MSN CCRC Manager Cancer Clinical Trials Office

Donna Smith, M.D. Gynecology Oncology

Sheryl Svoboda Dietician, Cancer Center

Michael Woods, MD Urology

Prepared by: V. Dimovic, CTR


Medical Services

All patients at the Cardinal Bernardin Cancer Center begin with a visit to one of the center’s specialty or multidisciplinary clinics . There, the patient and family meet with the cancer specialist responsible for establishing an individual treatment plan and coordinating care . Within our unique multidisciplinary setting, a patient will meet with a team of cancer experts that may include surgeons, medical oncologists, radiation oncologists, radiologists, pathologists and plastic surgeons . These specialists work together to evaluate a patient’s condition . During the same visit, patients might also meet with a nutritionist, nurse, social worker or other supportive staff .

Programs & ServicesBelow is a list of our programs and services for cancer care: www .loyolamedicine .org

Bone Marrow Transplantation

Breast Cancer

Breast Care

Breast Oncology Center

CAN-HELP Cancer Information Service

Cancer Genetics Evaluation Program

Cancer Risk Assessment & Prevention

Cancer-Pediatric Hematology & Oncology Through our membership in the Children’s Oncology Group, we participate in clinical trials and studies for pediatric conditions such as: (Leukemia, Lymphoma, Brain Tumors, Neuroblastoma, Wilm’s Tumor, Rhabdomyosarcoma & Other Soft Tissue Sarcoma, Bone Malignancies)

Art Therapy

Cancer Survivorship Program

Caregivers Class for Bone Marrow Transplant Patients

Centers for Fitness

Chaplain Services

Chemotherapy Classes

Clinical Research

Coleman Foundation Image Renewal Center

Gastroenterology Services

Gastrointestinal Oncology Center

Gynecologic Oncology Services

Head and Neck Oncology Clinic

Hematology Clinic

Hematology/Oncology Services

Home Care & Hospice

Image Renewal Center

Melanoma Clinic

Neuro-Oncology Clinic

Nutrition Services

Psychology Support Services

Radiation Oncology Services

Screening and Early Detection - Cancer

Skin Cancer and Mohs Micrographic Surgery Center

Speech Therapy

Surgical Oncology

Thoracic and Lung Oncology Program

Urologic Oncology Clinic

http://www.loyolamedicine.org/Medical_Services/Cancer/Resources/CAN_HELP.cfm

http://www.loyolamedicine.org/Medical_Services/Services_A-Z/Bone-Marrow-Transplantation.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/Breast-Oncology-Center.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/Breast_Care/index.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/Breast-Oncology-Center.cfm



http://www.loyolamedicine.org/Medical_Services/Cancer/Support_Services/Cancer_Genetics.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/risk.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/Support_Services/Cancer_Survivorship.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/image_renew.cfm


http://www.loyolamedicine.org/Medical_Services/Services_A-Z/Gastroenterology-Services.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/GI_Oncology/Index.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/Gyne_Onc.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/head_neck_onc.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/hema_clinic.cfm

http://www.loyolamedicine.org/Medical_Services/Services_A-Z/Hematology-Oncology-Services.cfm


http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/mela_clinic.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/neuro_onc_clinic.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/Support_Services/Psychology_Support.cfm

http://www.loyolamedicine.org/Medical_Services/Services_A-Z/Radiation-Oncology-Services.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/scrn_early_det.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/scrn_early_det.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/skin_cancer.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/skin_cancer.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/surgical_oncology.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/lung_onc.cfm

http://www.loyolamedicine.org/Medical_Services/Cancer/What_We_Do/uro_onc_clinic.cfm


Primary Site Table/2011

The following table summarizes the primary sites by gender for 2011 . The top five most frequent occurring cancers at Loyola University Medical Center in 201 were: breast, prostate, lung, skin, & corpus uteri

Primary Site Male Female Analytic Non-Analytic Total

All Sites 1246 1361 2336 271 2607

Oral Cavity 85 38 106 17 123

Lip 1 2 2 1 3

Tongue 20 10 25 5 30

Oropharynx 1 1 1 1 2

Hypopharynx 2 0 2 0 2

Other 61 25 76 10 86

Digestive System 231 167 372 26 398

Esophagus 24 6 29 1 30

Stomach 30 17 44 3 47

Colon 47 35 70 12 82

Rectum 39 25 56 8 64

Anus/Anal Canal 5 8 11 2 13

Liver 19 6 25 0 25

Pancreas 50 44 94 0 94

Other 17 26 43 0 43

Respiratory System 135 109 225 19 232

Nasal / Sinus 7 1 11 0 11

Larynx 18 4 18 4 22

Lung/Bronchus 107 100 192 15 207

Other 30 19 38 11 49

Blood & Bone Marrow 135 97 181 51 232

Leukemia 80 55 109 26 135

Multiple Myeloma 25 23 34 14 48

Other 30 19 38 11 49

Bone 1 2 3 0 3

Connective/ Soft Tissue 12 11 21 2 23

Skin 83 70 137 16 153

Melanoma 79 66 129 16 145

Other 4 4 8 0 8

Primary Site Male Female Analytic Non-Analytic Total

Breast 4 285 262 27 289

Female Genital 0 272 248 24 272

Cervix Uteri 0 39 36 3 39

Corpus Uteri 0 146 138 8 146

Ovary 0 46 43 3 46

Vulva 0 22 15 7 22

Other 0 19 16 3 19

Male Genital 208 0 193 15 208

Prostate 191 0 178 13 191

Testis 14 0 12 2 14

Other 3 0 3 0 3

Urinary System 163 76 206 33 239

Bladder 90 33 103 20 123

Kidney/Renal 69 39 95 13 108

Other 4 4 8 0 8

Brain & CNS 58 53 109 2 111

Brain (Benign) 3 3 6 0 6

Brain (Malignant) 22 9 31 0 31

Other 33 41 72 2 74

Endocrine 41 98 133 6 139

Thyroid 29 86 111 4 115

Other 12 12 22 2 24

Lymphatic System 73 55 97 31 128

Hodgkin’s Disease 18 9 13 14 27

Non-Hodgkin’s 55 46 84 17 101

Unknown Primary 12 19 30 1 31

Other/Ill-Defined 5 9 13 1 14

Table: 1

Analytic: A cases first diagnosed and / or receiving first course treatment at the facility, or diagnosed at autopsy.

Non-Analytic: Any case diagnosed at another facility and receiving all first course treatment at that facility, then seen at Loyola University medical Center for subsequent treatment.


Graph 1: Incidence per Year

Data shows that the number of cases diagnosed and treated at Loyola University Medical Center in 2011 .

3000

2500

2000

1500

1000

500

0

# of Cases# o

f C

ases

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

2419 23572144

23112602

2806

2497

27752616 2607

In most of the 2011 cases, a total of 50% (1279), patients received their initial diagnosis at LUMC; 37% (966) of patients were diagnosed elsewhere, but came in our facility to be treated; 3% (91) of patients were diagnosed at our facility and all their first course of therapy was done elsewhere; and 10% (271) of the patients came here for treatment of recurrent disease. (See Figure 1)

Figure 1: Class of Case

37%

10%

3%

50%

Class 0

Class 1

Class 2

Class 3

Most of the 2011 cases, 52% (1,344) of the patients were seen from Cook county, followed by 19% (493) from DuPage, 9% (251) from Will, 5% (122) from Kane. Out-of-state cases accounted for 1% (63) and the remaining others acco unted for 13% (348).

Data Analysis


Figure 2: Cases by Diagnosis County

Cook

DuPage

Will

Kane

Other

Out of State

9%

.1%

5%

19%

13%

52 %

For all analytical cases, the most frequent site is Breast 29% (262). Next in frequency is the Lung 21% (192); Prostate with 20% (178) Corpus Uteri with 15% (138) and finally Skin with 15% (137`) (See Graph 2)

Graph 2: Five Major Sites

0.0108 in

300

250

200

150

100

50

04

93

258

99

0

178

138

0

6374#

of

Cas

es

Breast Lung Prostate Corpus Uteri Skin

Male

Female

For new analytic cases 53% (1229) were female and 47% (1107) male. Graph 3 below shows that the diagnosis of cancer was most found in the 60-69 year range for males and females.

Data Analysis


Graph 3: Age by Sex

400

350

300

250

200

150

100

50

0

# o

f C

ases

Age of Patients

00-09 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99

Male

Female

411 1114

2920

54

39

178

104

237

328

247

101

6

267

351

215

109

11

For all analytic combined staged cases: 7% (157) were stage 0; 29% (682) Stage I; 15% (359) Stage II; 14% (337) Stage III; 16% (369) Stage IV, 3% (63) Unknown Stage and 16% (369) accounted for non-applicable cases for staging.

Graph 4: AJCC Stage by Sex

0

50

100

150

200

250

300

350

400

450

# o

f C

ases

AJCC Stage

0 I II III IV UNK N/A

59

438

98

244

159

200

168169 163

206

3924

164

205

Male

Female

Table 2: Age by Sex

Age Range Male Female

0-19 11 4

20-29 14 11

20-29 20 29

30-39 39 54

40-49 104 178

50-59 237 267

60-69 328 351

70-79 247 215

80-89 101 109

90+ 6 11

Total (2,236) 1107 1229


Cancer Incidence by Sex & Site with the State & NationalThe American Cancer Society National estimates for site and sex distribution for all races were used to compare the estimates with Loyola University Medical Center data and the State of Illinois Cancer Statistics . The numbers reported are percentages of the total cases by sex . For the male population as compared to both the state and the nation, we observed quite a high incidence of Leukemia, Skin (Melanoma), Pancreas, Stomach and Bladder but a lower level of Prostate, Lung, and Lymphoma .

For the female population as compared to the state & nation, we observed quite a high incidence of Corpus Uteri, Skin, Pancreas and Ovary, but a lower level of Breast, Lung & Colorectal .

Table 3: Males

Site

LUMC % (1,106)

Illinois % (32,630)

Year-2008

National % (822,300) Year-2011

Table 4: Females

SiteLUMC % (n=1,228)

ILLINOIS % (n=31,207)

NATIONAL% (n=774,370)


Notice: When comparing survival rates between our cancer program and all other CoC-accredited cancer programs: if the confidence intervals of stage-specific or overall survival rates overlap after five years, then there is no statistical difference between survival rate of patients at or facility with that of other CoC-accredited cancer programs

Comparison of Survival between Loyola University Medical Center and National Cancer Data base is shown below (Table 5) for the five major sites . Survival rate measures the percentage of patients with a specific type of cancer who are still alive after a certain period of time . In this case, time frame used from LUMC was from year 2004 through 2008 and time frame used from NCDB was from 2003–2005 . Categories for our survival comparison will include the five major sites; breast, lung, prostate, melanoma and endometrial . For most cancers, the survival rate, measured as five-year survival, is best when the cancer is found in an early stage . Early diagnosis, followed by the best treatment that stage, can increase the chances for survival and can decrease post-treatment problems . Survival is usually lower when cancer is found at a later stage .

Cancer observed survival rates below indicate how many patients were still alive five years after diagnosis but are not adjusted for many factors which affect survival . The survival rates depicted in the table below illustrates for all deaths, regardless of cause . Patients may have been diagnosed somewhere else and treated here or diagnosed here and treated somewhere else .

The comparison data are from the Commission on Cancer American College of Surgeons, ©2012 NCDB Benchmark Reports .

Table 5: 5-Year Survival Comparison, LUMC vs NCDB

Site / AJCC Stage LUMC (%) NCDB (%) Site / AJCC Stage LUMC (%) NCDB (%)

Patie

nt C

are

Eval

uatio

n St

udy

of

Mel

anom

a 20

07–2

011


The skin is the largest organ of the body, with a total area of about 20 square feet . The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold .

Skin has three layers:

• The epidermis, the outermost layer of skin, provides a waterproof barrier and creates our skin tone .

• The dermis, beneath the epidermis, contains tough connective tissue, hair follicles, and sweat glands .

• The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.

WebMD Image Collection: Human Anatomy

Patie

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are

Eval

uatio

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of

Mel

anom

a 20

07–2

011

Gerard Aranha, MD Chairman, Cancer Committee Surgical Oncology

Violet Dimovic, CTR Oncology Data Management Manager, Cancer Registry

Constantine Godellas, MD, FACS Professor and Vice Chair, Program Director Oncology Program Cancer Liaison Physician Department of Surgery


Loyola University Medical CenterPatient Care Evaluation Study of Melanoma

2007–2011

The skin’s color is created by special cells called melanocytes , which produce the pigment melanin . Melanocytes are located in the epidermis . Melanoma is a skin cancer that starts in the melanocytes . Melanoma usually appears as an irregular brown, black and or red spot or existing mole that begins to change color, size or shape .

According to the American Cancer Society, it appears most commonly on the trunk area in fair-skinned men and on the lower legs in fair skinned women . At LUMC, we identified 30% (230 cases from the 762 cases) to be in the trunk area . See Table 1 for details .

Table 1: # of Cases by Site

Site # of cases

Lip 3

Eyelid 6

External Ear 26

Face 132

Scalp & Neck 68

Trunk 230

Upper Limb & Shoulder 133

Lower Limb & Hip 126

Skin, Not Otherwise specified 35

Vulva 2

Penis 1

Total 762



2007–2011

The American Cancer Society estimates that 5% of cancers in the U .S . will be melanoma of the skin . This means that in year 2011, 76,660 will be diagnosed and 11,980 people will die from this disease .

We used the data base of the cancer registry at Loyola University Medical Center to examine trends in patient care and to determine patient outcomes and make crude comparisons to available national database . Between 2007 and 2011, there were 762 new melanoma cases of the skin diagnosed and / or treated at LUMC . The purpose of the following analysis is to compare the population of melanomas treated at LUMC with patients having the identical disease who are listed in the national database . We will attempt to explain any differences and propose specific interventions or adjustments in data collection which may be helpful in the future . These analyses will question whether or not similarity treated patients have improved outcomes in a University Hospital based setting and whether this is a result of better patient care .

We will also review the primary site coding, stage, histological distribution, prognostic factors, such as, Breslow tumor thickness, ulceration, mitotic rate, positive sentinel nodes, vertical growth phase (VGP) and if BRAF mutation was identified .

Table 2 highlights the melanoma of the skin diagnosed per year . Lymphoma cancer cases make up (~6%) of Loyola’s overall cancer caseload . Of the patients from 2007-2011 year, 402 (53%) were male and 360 (47%) were female . The male/ female distribution is very similar to the national figures .

(LUMC (402) Male 53%) (NCDB (43,890) Male 58%);

(LUMC (360) Females 47%), (NCDB (32,440) Females 43%).

Table-2: Caseload /Year

Total 2007 2008 2009 2010 2011

LUMC 762 (100%) 189 (25%) 167 (22%) 142 (19%) 139 (18%) 125(16%)



2007–2011

Age group ranged from 10 thru 99 . Twenty-three percent (23%) of the patients were diagnosed between ages 50–59 . See Table 3 and Graph 1 below for details .

Table-3: Age by Sex (2007-2011)

Age Range Male Female

10-19 4 1

20-29 3 23

30-39 31 40

40-49 50 76

50-59 88 87

60-69 85 56

70-79 95 48

80-89 42 25

90-99 4 4

Total 402 360

Graph-1: Age by Sex (2007-2011)

# o

f C

ases

Age of Patients

10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99

0

20

40

60

80

100

Male

Female

14

23

3

40

31

76

50

878885

95

42

4

56

48

25

4



2007–2011

Graph-2: Stage by Sex (2007–2011)

# o

f C

ases

AJCC Stage

0 I II III IV

0

50

100

150

200

Male

Female

178

199

109102

33

53

23

38

1710

As illustrated in Graph 2 and Table 4, 49% (377) of the patients for male and female were found to have stage I disease at time of diagnosis . No unknown stages were detected .

Table 4: Stage by Gender

AJCC Stage Male Female Total

0 102 109 211 (28%)

I 199 178 377 (49%)

II 53 33 86 (11%)

III 38 23 61 (8%)

IV 10 17 27 (4%)

Total 402 360 762 (100%)



2007–2011

Table 5: Distribution by Histology & AJCC Stage

0 1 1A 1B 2 2A 2B 2C 3 3A 3B 3C 4

Melanoma in situ 113

Malignant melanoma NOS 8 32 19 1 7 9 1 10 4 2 1 18

Nodular Melanoma 1 4 12 2 14 11 6 8 4 2 3 5

Malignant Melanoma Regressing 1 1

Amelanotic Melanoma 1

Hutchinson’s melanotic freckle 92

Malignant melanoma In Hutchinson’s freckle 3 40 11 3

Superficial Spreading Melanoma in situ 6

Superficial Spreading Melanoma 8 168 59 15 6 15 2 4 1 2

Acral lentiginous melanoma malignant 4 4 1 2

Desmoplastic melanoma malignant 1 2 1 1

Epithelioid cell melanoma 1 1 1

Spindle cell melanoma 1 1 1 2 1 1

Total (762) 211 21 249 107 5 42 31 8 37 10 9 5 27

Distribution by AJCC Stage showed 28% (211) to be Stage 0; 49% (377) Stage I; 11% (86) Stage II; 8% (61) Stage III and 4% (27) to be Stage IV.

As illustrated in Table 5, the histology most commonly seen in our institution is malignant superficial spreading melanoma followed by melanoma in situ and malignant melanoma not otherwise specified as third.



2007–2011

The system most often used to stage melanoma is the American Joint Committee on Cancer (AJCC) TNM system . The TNM system contains 3 key pieces of information:

• T stands for tumor (how far it has grown within the skin and other factors). The T category is assigned a number (from 0 to 4) based on the tumor’s thickness (how far down it has grown) . It may also be assigned a small letter (a) or (b) based on ulceration and mitotic rate, which are explained below .

• N stands for spread to nearby lymph nodes (small bean-shaped collections of immune system cells, to which cancers often spread first) . The N category is assigned a number (from 0 to 3) based on whether the melanoma cells have spread to lymph nodes or are found in the lymphatic channels connecting the lymph nodes . It may also be assigned a small letter a, b, or c, as described below .

• The M category is based on whether the melanoma has metastasized (spread) to distant organs, which organs it has reached, and on blood levels of a substance called LDH .

As a note, Clark levels were previously a primary requirement for sub-classifying pT1 lesions according to the American Joint Committee on Cancer (AJCC) 6th edition TNM classification system and are commonly reported . Anatomic level has been replaced by mitotic rate in the AJCC 7th edition (implemented in January 2010) for sub-classifying pT1 lesions as T1a or T1b, Clark level IV or V is referred to as a tertiary criterion for T1b in cases with no ulceration and “if mitotic rate cannot be determined .” Clark level are therefore reported whenever it would form the basis for upstaging T1 lesions .

Key Facts:*New guidelines were implemented in January 2010*Tumor thickness and ulceration remain*Mitotic rate has replaced Clark level for stratification of thin melanomas*Sentinel node biopsy (SLNB) is recommended for: T1b, T2, T3 and T4*SLNB is recommended requirement for inclusion in clinical trials

There are 2 types of staging for melanoma:• Clinical staging is based on what is found on physical exam, biopsy/removal of the main melanoma, and any imaging

tests that are done . • Pathologic staging uses all of this information, plus what is found during biopsies of lymph nodes or other organs if they

are done .

The pathologic stage (determined after the node biopsy) may actually be higher than the clinical stage (determined before the node biopsy) if the biopsy finds cancer in new areas .



2007–2011

T categories The T category is based on the thickness of the melanoma and other key factors seen in the skin biopsy .

Tumor thickness: The pathologist looking at the skin biopsy measures the thickness of the melanoma under the microscope . This is called the Breslow measurement. The thinner the melanoma, the better the prognosis . In general, melanomas less than 1 millimeter (mm) thick (about 1/25 of an inch) have a very small chance of spreading . As the melanoma becomes thicker, it has a greater chance of spreading .

Mitotic rate: Another important aspect for tumors is the mitotic rate . To measure this, the pathologist counts the number of cells in the process of dividing (mitosis) in a certain amount of melanoma tissue . A higher mitotic rate (having more cells that are dividing) means that the cancer is more likely to grow and spread . The mitotic rate is used to help stage thin melanomas (T1; see below) .

Ulceration: Ulceration is a breakdown of the skin over the melanoma . Melanomas that are ulcerated tend to have a worse prognosis .

The possible values for T are:

TX: Primary tumor cannot be assessed .

T0: No evidence of primary tumor .

Tis: Melanoma in situ (The tumor remains in the epidermis, the outermost layer of skin) .

T1a: The melanoma is less than or equal to 1 .0 mm thick (1 .0 mm = 1/25 of an inch), without ulceration and with a mitotic rate of less than 1/mm2 .

T1b: The melanoma is less than or equal to 1 .0 mm thick . It is ulcerated and/or the mitotic rate is equal to or greater than 1/mm2 .

T2a: The melanoma is between 1 .01 and 2 .0 mm thick without ulceration .

T2b: The melanoma is between 1 .01 and 2 .0 mm thick with ulceration .

T3a: The melanoma is between 2 .01 and 4 .0 mm thick without ulceration .

T3b: The melanoma is between 2 .01 and 4 .0 mm thick with ulceration .

T4a: The melanoma is thicker than 4 .0 mm without ulceration .

T4b: The melanoma is thicker than 4 .0 mm with ulceration .

• Pathologic staging uses all of this information, plus what is found during biopsies of lymph nodes or other organs if they are done .



2007–2011

N categoriesThe possible values for N depend on whether or not a sentinel lymph node biopsy was done .

The clinical staging of the lymph nodes, which is done without the sentinel node biopsy, is listed below .

NX: Nearby (regional) lymph nodes cannot be assessed .

N0: No spread to nearby lymph nodes .

N1: Spread to 1 nearby lymph node .

N2: Spread to 2 or 3 nearby lymph nodes, OR spread of melanoma to nearby skin or toward a nearby lymph node area (without reaching the lymph nodes) .

N3: Spread to 4 or more lymph nodes, OR spread to lymph nodes that are clumped together, OR spread of melanoma to nearby skin or toward a lymph node area and into the lymph node(s) .

Following a lymph node biopsy, the pathologic stage can be determined, in which small letters may be added in some cases:

• Any Na (N1a or N2a) means that the melanoma is in the lymph node(s), but it is so small that it is only seen under the microscope (also known as microscopic spread) .

• Any Nb (N1b or N2b) means that the melanoma is in the lymph node(s) and was large enough to be visible on imaging tests or felt by the doctor before it was removed (also known as macroscopic spread) .

• N2c means the melanoma has spread to very small areas of nearby skin (satellite tumors) or has spread to skin lymphatic channels around the tumor (without reaching the lymph nodes) .

M categories The M values are:

M0: No distant metastasis .

M1a: Metastasis to skin, subcutaneous (below the skin) tissue, or lymph nodes in distant parts of the body, with a normal blood LDH level .

M1b: Metastasis to the lungs, with a normal blood LDH level .

M1c: Metastasis to other organs, OR distant spread to any site along with an elevated blood LDH level .



2007–2011

Stage groupingOnce the T, N, and M groups have been determined, they are combined to give an overall stage, using Roman numerals I to IV (1 to 4) and sometimes subdivided using capital letters . This process is called stage grouping.

Stage 0Tis, N0, M0: The melanoma is in situ, meaning that it is in the epidermis but has not spread to the dermis (lower layer) .

Stage IAT1a, N0, M0: The melanoma is less than 1 .0 mm in thickness . It is not ulcerated and has a mitotic rate of less than 1/mm2 . It has not been found in lymph nodes or distant organs .

Stage IBT1b or T2a, N0, M0: The melanoma is less than 1 .0 mm in thickness and is ulcerated or has a mitotic rate of at least 1/mm2, OR it is between 1 .01 and 2 .0 mm and is not ulcerated . It has not been found in lymph nodes or distant organs .

Stage IIAT2b or T3a, N0, M0: The melanoma is between 1 .01 mm and 2 .0 mm in thickness and is ulcerated, OR it is between 2 .01 and 4 .0 mm and is not ulcerated . It has not been found in lymph nodes or distant organs .

Stage IIBT3b or T4a, N0, M0: The melanoma is between 2 .01 mm and 4 .0 mm in thickness and is ulcerated, OR it is thicker than 4 .0 mm and is not ulcerated . It has not been found in lymph nodes or distant organs .

Stage IICT4b, N0, M0: The melanoma is thicker than 4 .0 mm and is ulcerated . It has not been found in lymph nodes or distant organs .

Stage IIIAT1a to T4a, N1a or N2a, M0: The melanoma can be of any thickness, but it is not ulcerated . It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope . There is no distant spread .



2007–2011

Stage IIIBOne of the following applies:

T1b to T4b, N1a or N2a, M0: The melanoma can be of any thickness and is ulcerated . It has spread to 1 to 3 lymph nodes near the affected skin area, but the nodes are not enlarged and the melanoma is found only when they are viewed under the microscope . There is no distant spread .

T1a to T4a, N1b or N2b, M0: The melanoma can be of any thickness, but it is not ulcerated . It has spread to 1 to 3 lymph nodes near the affected skin area . The nodes are enlarged because of the melanoma . There is no distant spread .

T1a to T4a, N2c, M0: The melanoma can be of any thickness, but it is not ulcerated . It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma . There is no distant spread .

Stage IIICOne of the following applies:

T1b to T4b, N1b or N2b, M0: The melanoma can be of any thickness and is ulcerated . It has spread to 1 to 3 lymph nodes near the affected skin area . The nodes are enlarged because of the melanoma . There is no distant spread .

T1b to T4b, N2c, M0: The melanoma can be of any thickness and is ulcerated . It has spread to small areas of nearby skin or lymphatic channels around the original tumor, but the nodes do not contain melanoma . There is no distant spread .

Any T, N3, M0: The melanoma can be of any thickness and may or may not be ulcerated . It has spread to 4 or more nearby lymph nodes, or to nearby lymph nodes that are clumped together, OR it has spread to nearby skin or lymphatic channels around the original tumor and to nearby lymph nodes . The nodes are enlarged because of the melanoma . There is no distant spread .

Stage IVAny T, any N, M1(a, b, or c): The melanoma has spread beyond the original area of skin and nearby lymph nodes to other organs such as the lung, liver, or brain, or to distant areas of the skin, subcutaneous tissue, or distant lymph nodes . Neither spread to nearby lymph nodes nor thickness is considered in this stage, but typically the melanoma is thick and has also spread to the lymph nodes .



2007–2011

Pathologic Stage GroupingsStage 0 Tis N0 M0Stage IA T1a N0 M0Stage IB T1b N0 M0T2a N0 M0Stage IIA T2b N0 M0T3a N0 M0Stage IIB T3b N0 M0T4a N0 M0Stage IIC T4b N0 M0Stage IIIA T1-4a N1a M0T1-4a N2a M0Stage IIIB T1-4b N1a M0T1-4b N2a M0T1-4a N1b M0T1-4a N2b M0T1-4a N2c M0Stage IIIC T1-4b N1b M0T1-4b N2b M0T1-4b N2c M0Any T N3 M0Stage IV Any T Any N M1

Note that for cutaneous melanoma, clinical and pathologic stage groupings differ for stage III. The complete clinical stage groupings are shown below for comparison.

Clinical Stage GroupingsStage 0 Tis N0 M0Stage IA T1a N0 M0Stage IB T1b N0 M0T2a N0 M0Stage IIA T2b N0 M0T3a N0 M0Stage IIB T3b N0 M0T4a N0 M0Stage IIC T4b N0 M0Stage III Any T ≥N1 M0Stage IV Any T Any N M1



2007–2011

The type of treatment of melanoma skin cancer depends on the stage, location and overall health of patients .

Stage 0: melanomas have not grown deeper than the epidermis and are usually treated by surgery .

Stage 1: melanoma is treated by wide excision . May include sentinel lymph node biopsies, if stage is 1B . If sentinel node is positive, a lymph node dissection is recommended . A sentinel lymph node is defined as the first node to receive lymphatic drainage from a primary tumor . There may be more than 1 sentinel node for some tumors . The clinical rationale for sentinel lymph node identification and separate evaluation is based on the assumption that metastatic involvement of a sentinel node increases the likelihood that other, more distant nodes may also contain metastatic disease . Conversely, if sentinel nodes are negative, other regional nodes would be less likely to contain metastasis .

Stage 2: melanoma is treated by wide excision and sentinel node biopsy and treatment with interferon or other drugs or perhaps vaccines (adjuvant therapy after surgery) .

Stage 3: melanoma is treated by wide excision of the primary tumor and lymph node dissection . Adjuvant therapy with interferon and another option may be to give radiation therapy to the areas where the lymph nodes were removed . If several melanomas are present, it is recommended that all be removed . If this is not possible, options include injections of Bacille Calmette-Guerin (BCG) vaccine or interleukin-2 directly into the melanoma, radiation therapy, or applying the topical immunotherapy imiquimod . For melanomas on an arm or leg, another possible option is isolated limb perfusion (infusing the limb with a heated solution of chemotherapy) . Other possible treatments include chemotherapy, immunotherapy with cytokines, or both combined (bio chemotherapy) or taking part of a clinical trial .

Stage 4: melanomas have spread to distant lymph nodes or other parts of the body that cause symptoms that may be removed surgically . Other metastases that cannot be removed surgically may be treated with radiation, immunotherapy, targeted therapy or chemotherapy .



2007–2011

Treatment combination for all LUMC cases is indicated in Table 6 below .

Table 6: Treatment Combination for All Cases Combined (LUMC)

Treatment Type # of Cases

Surgery 681

Surgery /Biological Response Modifier 30

Surgery / Chemotherapy 10

None 10

Surgery / Radiation 9

Biological Response Modifier 6

Chemotherapy / Radiation 4

Chemotherapy 4

Surgery / Radiation / Hormone 4

Radiation 2

Surgery / Radiation / Biological Response Modifier 1

Chemotherapy / Radiation / Biological Response Modifier 1

Total Cases 762 Surgery is the standard treatment for this disease and is necessary to remove not only the tumor but also some normal tissue around it in order to minimize the chances of metastases. As can be seen in Table 6 & 7, (735/762) 96% LUMC patients were treated with surgery alone or with other combination of treatment.



2007–2011

Table 7: Treatment Combination by Stage

Treatment Type Stage 0 Stage 1 Stage 2 Stage 3 Stage 4

Surgery 211 374 76 24 1

None 3 2 3

Surg/Chem 7 2

Surg / BRM 7 19 3

Chemotherapy 1 2

Surg/ Radiation 2 5 2

Chem/ Radiation 1 3

Surg/Rad/BRM 2 2

BRM 1 5

Radiation 2

Surg/Rad/Horm 1

Chemo/Rad/BRM 1

Total # of cases (762) 211 377 86 61 27 S=Surgery C=Chemotherapy BRM=Biological Response Modifier H=Hormone O=Other



2007–2011

Further analysis indicated that approximately 248 (Stage 1B, 2, 2A, 2B, 2C, 3, 3A, 3B, 3C, & 4 patients underwent excisional procedures . This analysis has demonstrated that sentinel lymph node biopsy is underused in patients for whom the procedure is recommended on the established guidelines . As shown below in Table 8, 161/258 (62%) of the patients were treated according recommended guidelines .

Studies using the Surveillance, Epidemiology, and End Results (SEER) database and the National Cancer Data Base (NCDB) have demonstrated that SLNB is underused in patients for whom the procedure is recommended on the basis of established guidelines . In the most recent time period, nationally, only approximately 50% of patients with intermediate-thickness melanomas underwent an SLN, whereas, in our analysis 62% of patients underwent a completion nodal dissection . This was higher than the National Comprehensive Cancer Network and National Cancer Institute designated cancer centers . This high rate may account for the quality retrospective review that is conducted quarterly on melanoma cases to ensure accuracy of coding has been documented and appropriately submitted to the NCDB .

Table 8: Treatment Combination for Stage 1B thru 4

Stage # cases with surgery performed

# cases with surgery performed and no nodes removed

# of cases with surgery performed & sentinel lymph node biopsies

# of cases with surgery performed with lymph node dissection and without identified or stated as sentinel lymph node biopsies

1B 106 19 74 13

2, 2a, 2b, 2c 85 19 54 12

3, 3a, 3b, 3c 57 0 32 25

4 10 6 1 3

Total 258 44 161 53

Sentinel node biopsy (SLNB) has now become part of the standard treatment for melanoma and is useful in detecting microscopic nodal disease in patients without clinical adenopathy . Surgeons locate sentinel or guarded nodes, by injecting a radioactive substance and a blue dye into the site of the melanoma . Once these agents have migrated to the sentinel nodes, the nodes can be identified . Microscopic examination of tissue from the excised nodes determines whether the melanoma has metastasized from its original site .



2007–2011

According to the National Comprehensive Cancer Network (NCCN), SLNB is not recommended for patients with in situ melanoma (stage 0) or stage 1A melanoma that is 1 .0 mm or less with no adverse features but is recommended or at least discussion of, for patients with T1b, T2, T3 and T4 melanoma . Generally, according to the guidelines, a patient who has undergone a wide local excision (WLE) when the melanoma was removed do not benefit as much from having a SLNB because the wide excision distorts the lymphatic drainage basin by cutting it up . These guidelines are clearly important to help provide treatment recommendations in a complex and rapidly changing field such as melanoma . More accurate staging and a lower rate of postoperative complications are the main reasons for having a sentinel lymph node biopsy . Nodal status is the most significant predictor of disease-free survival and is essential to establish criteria for future adjuvant trials . Prompt staging leads to earlier treatment .

Tables & Graphs below illustrate the comparison calculations of the observed 5-year survival rate by the Actuarial, Life Table Method (calculates the proportion surviving to each point in time that death occurs) from Loyola University Medical Center to the National combined data .

Table-6 LUMC (Kaplan-Meier ) Survival Rates (%) Cases Diagnosed in 2004–2008 (674 Cases Identified)

Years Total (674) 0-Year 1-Year 2-Year 3-Year 4-Year 5-Year

Stage 0 142 100 100 99.2 97.7 95.5 93.3

Stage I 362 100 98.2 96.4 93.8 91.8 88.7

Stage II 85 100 92.8 84.0 80.1 72.6 68.7

Stage III 61 100 86.8 78.4 70.1 58.5 51.0

Stage IV 24 100 37.5 25.0 16.6 16.6 16.6 Unknown stage of disease has been eliminated from the survival calculation.

Graph-3: (Kaplan-Meier ) Survival Rates (%)

0 1 2 3 4 5

Per

cent

(%)

Years

0

I

II

III

IV

0

20

40

60

80

100



2007–2011

NCDB Observed Survival Rates (%) For Melanoma of the Skin Cases Diagnosed in 2003–2004 Data from 1,382 National Programs (ACoS) Table-7 NCDB (Kaplan-Meier ) Survival Rates (%)

Years Total (40,926)

0-Year 1-Year 2-Year 3-Year 4-Year 5-Year

Stage 0 8,418 100 99.1 97.8 95.8 94.1 92.1

Stage I 20,532 100 99.1 97.5 96.3 93.3 91.3

Stage II 5,993 100 94.9 86.7 78.5 72.5 66.9

Stage III 4,034 100 91.3 77.5 68.1 61.8 56.8

Stage IV 1,949 100 40.8 24.5 19.0 16.2 14.5

NCBD Rates (Cases diagnosed in 2003–2004)

0 1 2 3 4 5

Per

cent

(%)

Years

0

I

II

III

IV

0

20

40

60

80

100

Table 8: Survival comparison LUMC vs NCDB

Stage 5-Year Survival Rate for LUMC

5-Year Survival Rate for NCDB

0 93.3 92.1

I 88.7 91.3

II 68.7 66.9

III 51.0 56.8

IV 16.6 14.5 The analysis of survival data between our facility and the nation is intriguing. A statistically significant survival advantage is noted for stage II & IV but a lower rate on stage I and III.



2007–2011

In conclusion, recommendations proposed will require promoting an educational opportunity on adherence with established national treatment by way of seminars, conferences and or web-based tutorials . This concept will play an important role in keeping the cancer data registry personnel informed and up to date regarding understanding the criteria for selecting which patients should undergo SNL biopsy, and determining whether early identification of metastases in the SNL truly improves survival . These guideline recommendations need to be transformed into quality metrics that can be easily abstracted to entail a formal process with input from all relevant multidisciplinary teams . Measures will be implemented to demonstrate usability, relevance, feasibility, validity and reliability for purposes of collecting high quality data and submitting to the central or national organization for analysis .

Although putting forth and clarifying guidelines is an important endeavor, the challenge is to ensure that the thoughtfully developed guidelines are followed in everyday practice across the country on a routine basis . Practice guidelines are systematically developed statements that assist practitioners and patients in making decisions about care . Attributes of good guidelines include validity, reliability, reproducibility, clinical applicability, flexibility, clarity, multidisciplinary process, review of evidence, and documentation . Guidelines may be useful in producing better care and decreasing cost and improvements in outcomes and overall medical practice .

A combination of the above approaches will be required depending on the disease and type of guideline, and the work of ensuring guideline adherence may prove to be the most challenging aspect of ensuring high-quality cancer care for patients with melanoma .


Low Dose Rate to High Dose Rate Brachytherapy Transition: Maintaining outcomes / Decreasing staff doseEdward Melian, MDMurat Surucu, PH.D.Anil Sethi, PH.D.Iris RusuMichael MyszMing XuJohn Roeske, PH.D.Teresita McCoo, MSCourtney PerinoDolores FrancoBahman Emami, MD

Acknowledgements: Arun Paul, Mary Kwasny, Margo Shoup, MD Constantine Godellas, MD Darl Vandevender, MDGerard Aranha, MD

Background-The Problem:• Soft tissue sarcomas (STS) are rare cancers of the muscle, fat, blood vessels, fibrous

tissue, or supporting tissues of the body . The international annual incidence rate is 1 .8–5 .0 per 100,000 with an estimated number of 11,280 new cases and 3,900 deaths in the United States .

• The use of brachytherapy (treatment with implanted radioactive isotopes) with surgery has helped avoid amputations for many patients .

• During surgery, the brachytherapy catheters are inserted in the tumor bed and the radioactive sources are loaded either manually (LDR) or using an afterloader machine (HDR) . LDR patients are required to stay in the hospital with the implanted radioactive sources for 4–5 days, whereas HDR is usually an outpatient treatment .

• At Loyola, patients were treated using low dose rate brachytherapy (LDR). Between 1993 through 2005 and after 2005 the treatments were delivered using high dose rate (HDR) after loading brachtherapy (BRT) .

Tran

sform

ing

the

Car

e of

Sof

t Tis

sue

Sarc

omas


Transforming the Care of Soft Tissue Sarcomas


LDR HDR

Time 5 days 5 days

Location Inpatient Outpatient

Cost Higher High

Dose to Personnel High Low

Radioactive Source Placement Manual by the Personnel Automatic using afterload machine

Dose Shaping Good Better

Brachytherapy catheters spaced by 1 cm apart, shown with dummy sources



Project Aim Statement:• To assess the outcome of the LDR and HDR treatments of soft tissue sarcoma patients in terms of

– Tumor local control, patient survival and complications – Dose to personnel– Time to stay in hospital

HDR catheters inserted into the tumor bed

Project Goals:• To evaluate LDR and HDR treatments and ensure this shift of treatment management did not affect patient care, patient

outcomes (tumor control and complications) and personnel in a negative manner .

HDR catheters connected to the after load



Solutions Implemented:• Before 2005, 9 patients were treated with LDR and after 2005,

24 patients received their treatment using HDR• The patient care was shifted from inpatient to outpatient care• Procedures were developed for nursing care • Therapists were trained to operate the new machinery and handling

of the catheters

Results:

5 Year Kaplan-Meier Estimates of: %

Local Control 87

Overall Survival 77

Disease Specific Survival 81

HDR LDR

Acute Severe Complications 4/24 1/9

Late Severe Complications 3/24 1/9

HDR dose distribution tailored to the tumor bed

0 50 100 150 200

Loca

l Co

ntro

l

Time from Brachytherapy (Months)

0

0.2

0.4

0.6

0.8

1.0

+ CensoredLogrank p=0.8178

HDRLDR

Transforming the Care of Soft Tissue Sarcomas Effect of Tumor Size on Complications

NO Yes

Tum

or

Siz

e (c

m)

Severe Acute Complications

0

5

10

15

20

25



Analysis of Results-Patient Care:• The tumor control was similar with LDR vs HDR, with no change in local control with the technology shift• The treatment complication rate likewise was similar with LDR and HDR.• All complications were seen in patients with larger tumors needing more extensive surgery.

Analysis of Results-Exposure to Personnel:• Although the dose to personnel was lower than the occupational dose limits for both treatment techniques, it was

significantly less with HDR– In LDR, the radioactive sources are implanted manually by the radiation oncology team including nurses, physicians,

technologists, and medical physicists even with ideal source handling personnel increasing staff radiation exposure– In HDR, the radiation oncology team stays outside the room and an afterloader machine that houses the radioactive

source, extends the source into the catheters without any personnel handling the sources • The doses to the personnel was estimated to be 20 mrem per patient for LDR, where as it was < 1 mrem / patient for HDR

treatments

Lessons Learned:• HDR treatment was as effective as the LDR treatment • HDR achieved less radiation exposure to staff• The complication rate was not increased by HDR• The patients moved from being inpatient to outpatient with the shift of treatment from LDR to HDR• Brachytherapy was more effective with less complication for the smaller tumors

Next Steps:• The smaller tumors had better overall survival, and fewer complications. Therefore the brachytherapy treatment might be

offered to these patients in early stages of their disease while their tumors are small . • Since the complication rate was increased with the tumor size, we are evaluating whether a maximum tumor size should

be used when offering brachytherapy for these patients .



Table-1 LUMC (Kaplan-Meier ) Soft Tissue Sarcoma Survival Rates (%) Cases Diagnosed in 2004 – 2008 (79 Cases Identified)

Years Total (79) 0-Year 1-Year 2-Year 3-Year 4-Year 5-Year

Stage 0 0 100 100 100 100 100 100

Stage I 34 100 100 100 100 95.2 95.2

Stage II 13 100 92.8 84.6 84.6 84.6 84.6

Stage III 19 100 84.2 73.6 73.6 55.2 33.1

Stage IV 13 100 53.8 44.8 35.8 26.9 13.4 Note: Non-Applicable cases that did not require staging are excluded from the survival calculation

LUMC Survival Rates for Soft Tissue Sarcom a (2004–2008)

0 1 2 3 4 5

Per

cent

(%)

Years

0

I

II

III

IV

0

20

40

60

80

100



NCDB Observed Survival Rates (%) For Soft Tissue Sarcoma Cases Diagnosed in 2003–2005 Data from 1,295 National Programs (ACoS) Cases Diagnosed in 2003–2005 (10,904 Cases Identified) Table-2 NCDB (Kaplan-Meier ) Survival Rates (%)

Years Total (10,904)

0-Year 1-Year 2-Year 3-Year 4-Year 5-Year

Stage 0 0 100 100 100 100 100 100

Stage I 3804 100 95.3 91.3 87.4 84.4 81.1

Stage II 2213 100 91.9 82.3 75.2 70.9 67.1

Stage III 2922 100 83.5 67.9 58.2 52.1 47.4

Stage IV 1965 100 47.4 28.0 21.2 16.9 13.6

NCDB Rates (Cases diagnosed in 2003–2005)

0 1 2 3 4 5

Per

cent

(%)

Years

0

I

II

III

IV

0

20

40

60

80

100

Table 3 Survival Comparison LUMC vs NCDB

Stage 5-Year Survival Rate for LUMC (2004-2008)

5-Year Survival Rate for NCDB (2003-2005)

0 100 100

I 95.2 81.1

II 84.6 67.1

III 33.1 47.4

IV 13.4 13.6 A statistically significant survival advantage is noted for stage I & II but a lower rate on stage III and no statistical difference between survivals for stage IV.

Factors affecting outcome for someone with soft tissue sarcoma depends on:• Whereitisinthebody• Thesizewhenitisdiagnosedandwhetherithasspread• Howdeepthetumorsisinthetissues• Thegrade-whatthecellslooklikeunderthemicroscope

In conclusion, radiation therapy is considered a standard adjuvant therapy for sarcomas when surgery alone is believed to be insufficient. Targeting radiation to sarcomas can be challenging because of their wide variation in anatomical locations and depths in the body.



Glossary of Terms:

Accession: The addition of new cancer cases to the Oncology Registry .

Each patient is assigned a separate and permanent number .

ACOS: American College of Surgeons

ACS: American Cancer Society

Class of Case: The class of case divides cases recorded in the database of the facility into categories of analytic and non-analytic . Analytic data includes cases diagnosed at the accessioning facility and/or administration of any of the first course of treatment after the *registry’s reference date . Non-analytic cases are first diagnosed and receive all of first course of therapy at another institution, or are diagnosed at autopsy or by death certificate only . Non-analytic cases are not usually included in routine treatment or survival statistics . Based on category, the cancer program selects cases to be used by their facility or to be reported to the central registry, as well as, the National Cancer Data Base (NCDB) .

Analytic: A case first diagnosed and / or receiving first course treatment at that facility, or diagnosed at autopsy .

Non-analytic: Any case diagnosed at another facility and receiving all of first course treatment at that facility, then seen at Loyola University Medical Center for subsequent treatment .

Class 0: Diagnosis at accessioning facility and the entire first course of treatment was performed elsewhere or the decision not to treat was made at another facility .

• Patients who elect to be treated elsewhere.

• Patients who are referred elsewhere for treatment for any reason. For example, lack of special equipment; proximity of a patient’s residence; financial, social or rehabilitative considerations

Class 1: Diagnosis at the accessioning facility, and all or part of the first course of treatment was performed at the accessioning facility . Patients diagnosed at the accessioning facility whose treatment plan is either not to treat or watchful waiting . Patients diagnosed at the accessioning facility who refuse treatment . Patients diagnosed at the accessioning facility who are not treatable or who were given palliative care only due to age, advanced disease, or other medical conditions . Patients diagnosed at the accessioning facility for whom it is unknown whether treatment was recommended or administered . Patients diagnosed at the accessioning facility for whom treatment was recommended, but it is unknown whether it was administered .



Patients diagnosed at a staff physician’s office who receive their first course of treatment at the accessioning facility . “Staff physician” refers to any medical staff with admitting privileges at the accessioning facility . Patients diagnosed at the accessioning facility who received all or part of their first course of treatment in a staff physician’s office

Class 2: Diagnosis elsewhere, and all or part of the first course of treatment was performed at the accessioning facility . Patient provided palliative care in lieu of first course treatment, or as part of the first course of treatment, at the accessioning facility .

Class 3: Diagnosis and all of first course treatment done elsewhere . Patient treated or managed at the accessioning facility, but first course of treatment

information is unknown . Patient for whom the accessioning facility developed a treatment plan or provided “second opinion” services, but the diagnosis and treatment was provided elsewhere . Patient treated for a recurrence or progression for a previously diagnosed malignancy .

NCDB: The National Cancer Database

References:

Illinois Cancer Facts & Figures American Cancer Society, Incidence 2011

AJCC Manual for Staging Sixth & Seventh Editions

National Cancer Data Base American College of Surgeons, Commission on Cancer

Electronic Registry Systems Cancer Data Management Database Systems 2011

College of American Pathologists www .cap .org CAP Cancer Protocols

NCCN Guidelines in Oncology-v .1 .2011 National Comprehensive Cancer Network, 2011

National Cancer Facts & Figures, ACS American Cancer Society, Inc ., Surveillance Research, CDC, 2011

http://www.cap.org

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