Miller, Daniel

PurposeWhile scatter from the patient is assumed to be the primary source of occupational radiation dose associated with fluoroscopically guided interventional procedures, the potential contribution of scatter from the x‐ray collimator assembly is unknown. The purpose of this work was to survey clinical x‐ray angiography systems to assess the potential contribution of collimator assembly scatter on occupational radiation dose.MethodsExperimental methods were designed to measure the relative contributions of scatter originating from within the collimator assembly of the x‐ray tube to total scatter, which included scatter from a patient‐simulating phantom. Measurements were acquired as a function of lateral distance from the x‐ray beam center using a posterior anterior (PA) projection and at a fixed location for variable right anterior oblique to left anterior oblique projections in the range −90º to 90º. For one system, the collimator assembly was partially disassembled to assess the scatter contribution of individual components. For two systems, 0.5 mm Pb was added to the inner surface of the collimator assembly cover and tested for efficacy to block collimator assembly scatter.ResultsConsidering all x‐ray systems and only the PA projection, collimator assembly scatter contributed 20–50% to total scatter. For x‐ray projection angles of −90º to 90º, the relative contribution of collimator assembly to total scatter was dependent on projection angle and ranged from 5% to 56%. X‐ray systems with kerma‐area product meters demonstrated higher collimator assembly scatter than those without. Considering all projection angles, the addition of 0.5 mm Pb to the inside of the collimator assembly cover reduced collimator assembly scatter from 28% to 16% of total scatter for both systems.ConclusionFindings from this work suggest that contemporary radiation safety practices and guidelines should be revised to account for scatter originating from the collimator assembly of angiographic x‐ray tubes.

Key Clinical Message Myxoinflammatory fibroblastic sarcoma is a rare sarcoma which typically presents in the extremities and is treated by definitive surgery. In recurrent disease, the reported utilization of radiotherapy is increasing, and more modern techniques such as intensity‐modulated radiotherapy may be improving long‐term outcomes.

192 Background: Patient privacy is of the utmost importance for the emotional needs of a cancer patient and their family. As an effort to improve privacy, quality, and coordination of care within our Radiation Oncology department, in 2016 a patient pager system was devised to inform patients to prepare for daily treatment rather than verbally call the patient's name in waiting rooms. Methods: During June 2016, patients undergoing daily radiation therapy participated in a six-question survey addressing various aspects of the paging service, privacy prior to pager use, and demographics. Six radiation therapists also participated in a 7-question survey addressing privacy and workflow. Participants rated their experience on a scale of 1 to 5 (1 being poor, 5 being excellent). Surveys were collected and retrospectively reviewed. Results: 42 patients completed the survey. Patients rated "Very Good" to "Excellent" for the following categories: “Paging system more convenient than being called”(4.6), “Protection of privacy”(4.6), “Easiness”(4.7) and whether “Pager should be utilized for all appointments” (4.3). Patients rated “Patient privacy when name is called” as "Good" to "Very Good" (3.7). Seven patients also underwent therapy prior to pager implementation and rated the new system in comparison as "Very Good" to "Excellent" for “Privacy protection”(4.6), “Efficiency” (4.6), and “Satisfaction” (4.6). Only 24 filled out demographic information. Of the 24 patients, 54% of patients were female, 87% were above the age of 50, and all patients were receiving at least 10 treatments. Staff rated "Fair" to "Very Good" for “More preparation time” (2.8), “Patient use difficulty”(3.2), “Patient positive feedback”(2.3), “Receiving patients” (2.2) and “Workflow” (2). However, “Patient privacy” was rated as "Very Good" to "Excellent" (4.2). Conclusions: Overall, patients and staff highly rated the paging system for protecting privacy in the waiting room. Patients who experienced waiting room procedure prior to pager implementation display greater satisfaction with a paging system. However, it did not change overall workflow. Our study shows clinics should prioritize patient privacy in the waiting room to improve the emotional needs of the patient.

Prostate cancer is the most common malignancy of men in the United States. Small-cell carcinoma (SCC), which typically presents as an aggressive lung malignancy, is a rare diagnosis within the setting of prostate cancer pathology. Due to its limited prevalence, little information regarding the treatment and prognosis of this disease in large populations is available. To date our current knowledge base is largely limited to case reports and retrospective case reviews. The mainstay of treatment for this particular histology most often involves a multimodality approach utilizing chemotherapy in conjunction with radiation therapy, androgen deprivation therapy, or prostatectomy. Here we present the case of an elderly 89-year-old Caucasian male who was diagnosed with SCC of the prostate. Despite proceeding with a course of definitive radiotherapy, the patient experienced rapid progression of disease and ultimately elected to discontinue radiation therapy and receive hospice care.

Recurrent invasive high-grade mucoepidermoid carcinoma of the larynx and hypopharynx is a rare occurrence. These tumors have been commonly associated with salivary gland tumors, most commonly the parotid gland. The patient usually presents with the following symptoms: hoarseness (if larynx is involved), or changes in voice character, sore throat, cough, odynophagia, dysphagia, otalgia, difficulty breathing, weight loss, lymphadenopathy. Here we present a case of a recurrent invasive high-grade mucoepidermoid carcinoma of larynx and hypopharynx. The patient was a 67-year-old male that originally presented in 2006. At that time he underwent a wide field laryngectomy, right thyroid lobectomy, and biopsy of the right digastric node. He was a clinical stage III, pT3N0M0. No adjuvant radiation therapy was given at that time. The patient remained asymptomatic until February 2014, when he presented with dysphagia and neck swelling. Positron emission tomography/computed tomography showed evidence of recurrence. The patient was treated with definitive intensity modulated radiation therapy (IMRT) with concurrent chemotherapy. Treatment for this disease is gathered by scattered case reports. If surgery is a possibility it is considered as first line therapy. Post-surgical radiation is then offered. However, in this case the recurrent tumor was located near the carotid artery, and thus surgery was not a possibility. Therefore, concurrent chemotherapy and radiation with IMRT and weekly cis-platinum was given. While the optimum combination of treatment has not yet been established because of the rarity of this cancer's location site, the current patient appeared to have an excellent response from the definitive IMRT and chemotherapy treatment.

Langerhan's cell sarcoma (LCS) is a rare neoplasm with a poor prognosis. To our knowledge, only sixty-six cases have been published. We discuss two patients who presented very differently with LCS, as well as a recently published review of all sixty-six cases. Our first case had a complicated history of metastatic, high-grade myxofibrosarcomas and presented with a single skin lesion of LCS which was treated with resection to a positive margin and adjuvant radiotherapy. The LCS recurred locoregionally and was again resected. The patient is alive two years after initial diagnosis. The second case presented with bone marrow and splenic involvement, leukocytosis, and thrombocytopenia. This patient had an excellent response to etoposide, prednisone, oncovorin, cyclophosphamide, and adriamycin, with normalization of the complete blood count, negative bone marrow biopsy at follow up, and splenectomy without viable neoplasm. This patient is alive without signs of disease at 16 months after initial diagnosis.

Hidradenocarcinoma is a rare aggressive form of cutaneous adnexal skin carcinoma originating from the sweat gland. Due to its low incidence, prognostic and treatment strategies are still being explored both for primary and advanced disease. This tumor most often presents as either solid or cystic appearing subcutaneous nodules, which may be associated with pruritus or ulceration. To date the mainstay of treatment for local disease has been surgical excision; however, the paucity of historical data available has shown that these tumors often behave aggressively with high rates of local recurrence, metastasis, and poor overall outcomes. There are few case reports describing the utility of radiation therapy in the treatment of hidradenocarcinoma. Herein, we present a case of metastatic apocrine hidradenocarcinoma in a 32-year-old Caucasian male. The patient initially underwent excisional biopsy which confirmed the diagnosis of poorly differentiated, highly infiltrative, apocrine hidradenocarcinoma. He received systemic chemotherapy for metastatic disease, followed by radiation therapy to areas of grossly palpable adenopathy. Prior to radiation therapy the patient had an enlarged hypermetabolic conglomerate of lymph nodes in the right axilla, and borderline enlarged low activity nodes within the left axilla. He received 3 cycles of chemotherapy followed by tamoxifen and radiation therapy (50.4 Gy in 28 fractions) to areas of progressive disease in the bilateral axilla, lower neck, and axillary skin. Following treatment, the patient had complete resolution of skin nodules and improvement of his pruritus. While the role of radiation therapy in the treatment of hidradenocarcinoma has not been well established, this case report demonstrated the potential benefit of external beam radiotherapy in the management of this rare disease.