240
Comments
Association Between White Blood Cell Count Following Radiation Therapy and Radiation Pneumonitis in Non-Small Cell Lung Cancer
International Journal of Radiation Oncology Biology Physics
of countermeasures intended to mitigate radiation-induced fibrosis after irradiation has been administered (9, 10). Keith A. Cengel, MD, PhD Charles B. Simone, II, MD Department of Radiation Oncology University of Pennsylvania Philadelphia, Pennsylvania
In Regard to Tang et al To the Editor: With great interest, we read the recent article by Tang and colleagues (1), which describes the association between radiation pneumonitis and leukocyte (white blood cell [WBC]) counts following radiation therapy. These data serve to reinforce the notion that an aberrantly robust inflammatory response may be a critical underlying factor in determining a patient’s sensitivity to radiation pneumonitis (2-4). Indeed, in studies using a Yucatan mini-pig wholebody radiation exposure model, we have observed that leukopenia resulting from increased relative dose to bone marrow is associated with a decrease in the slope of the dose-toxicity response curve for radiation pneumonitis (5). Conversely, the current analysis by Tang et al (1) presented in Figure 3 suggests that the presence of elevated WBC counts may be able to identify patients with an increased dose-pneumonitis response slope. The authors should be commended for their detailed analysis. However, critical questions remain, especially regarding the subjective nature in the diagnosis of radiation pneumonitis. Common Terminology Criteria for Adverse Events, version 3.0, for pneumonitis do not include any specific radiologic criteria, but rather these are included under the pulmonary fibrosis designation (6). From their methods, it appears the investigators used a subjective review of these multiple clinical and radiographic criteria under the heading of radiation pneumonitis, which is problematic given the unclear mechanistic nature of the linkage between radiation pneumonitis and radiation fibrosis. Given that this distinction is the underpinning of their study, it would be informative for the investigators to provide a more detailed description of these findings and criteria (7). To address the inherent difficulties in diagnosing radiation-induced lung injury, we have used an established, semi-quantitative scoring system for fibrosis in a recent study (8). We systematically evaluated radiation fibrosis in 44 consecutive patients receiving definitive radiation therapy for small cell lung cancer in our department, finding that radiation fibrosis scores at 1 year were highly predictive of long-term clinical pulmonary decline parameters such as dyspnea and decreases in pulmonary function test results. In support of the recent findings by Tang et al (1), we have analyzed the correlation between WBC levels and fibrosis in our study population and determined that patients with moderate to severe pulmonary fibrosis demonstrate similarly elevated WBC at the 3-month posteradiation therapy follow-up visit. If WBC levels are validated as a biomarker for radiation fibrosis risk, they could be highly useful in selecting patients for future trials
http://dx.doi.org/10.1016/j.ijrobp.2014.04.045
References 1. Tang C, Gomez DR, Wang H, et al. Association between white blood cell count following radiation therapy with radiation pneumonitis in non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2014;88: 319-325. 2. Ghafoori P, Marks LB, Vujaskovic Z, et al. Radiation-induced lung injury. Assessment, management, and prevention. Oncology (Williston Park) 2008;22:37-47. 3. Hill RP, Zaidi A, Mahmood J, et al. Investigations into the role of inflammation in normal tissue response to irradiation. Radiother Oncol 2011;101:73-79. 4. Stone HB, Moulder JE, Coleman CN, et al. Models for evaluating agents intended for the prophylaxis, mitigation and treatment of radiation injuries. Report of an NCI Workshop, December 3-4, 2003. Radiat Res 2004;162:711-728. 5. Wilson JM, Sanzari JK, Diffenderfer ES, et al. Acute biological effects of simulating the whole-body radiation dose distribution from a solar particle event using a porcine model. Radiat Res 2011;176: 649-659. 6. Trotti A, Colevas AD, Setser A, et al. CTCAE v3.0: Development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol 2003;13:176-181. 7. Mazeron R, Etienne-Mastroianni B, Pe´rol D, et al. Predictive factors of late radiation fibrosis: A prospective study in non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2010;77:38-43. 8. Hertan H, Torigian DA, Xanthopoulos EP, et al. Evolution of and predictors for pulmonary fibrosis following definitive thoracic radiation therapy. Int J Radiat Oncol Biol Phys 2013;87(suppl):S522-S523. 9. DiCarlo AL, Jackson IL, Shah JR, et al. Development and licensure of medical countermeasures to treat lung damage resulting from a radiological or nuclear incident. Radiat Res 2012;177:717-721. 10. Pietrofesa R, Turowski J, Tyagi S, et al. Radiation mitigating properties of the lignan component in flaxseed. BMC Cancer 2013; 13:179.
Reliability of the ACR Radiation Oncology In-Training Exam In Regard to Morris To the Editor: The American College of Radiology (ACR) has provided the Radiation Oncology In-Training (TXIT) examination for 30 years. It offers residents an opportunity for identification of areas for improvement relative to their peers at the same level of training. It permits program directors to assess strengths and potential gaps in their programs. We appreciate the opportunity to respond to Dr Morris’ editorial (1).
Volume 90 Number 1 2014
Comments
The author claims the ACR has been silent about how scores should be used, questions whether examinations are reliable and properly validated, and perceives few published data about the psychometric performance. The examination’s validity is compared to the American Board of Radiology’s (ABR) practice analysis approach (2). The ACR provides information regarding its intended use in the packets sent yearly to program directors. The psychometric performance exceeds standards with an alpha of 91.5%. Its mean biserial coefficient, mean item difficulty, and standard deviations are within acceptable standards. The ABR examination is a criterion-referenced occupational test, and the ACR TXIT examination is a norm-referenced educational test. The ACR provides program directors with mean normreferenced scores at the national, institutional, and individual levels. In 2014, the examination scores will be incorporated into the Radiological Society of North America myPortfolio tool as well as a guide to interpreting the results. The ACR publishes recent examinations on its Website, along with rationales that include annotated bibliographies. The ACR hopes this feedback will allow residents to assess progress and build competencies, with focused study efforts guided by these data. The ACR seeks quality and excellence in all endeavors. We understand that the process of professional assessment is ongoing and continuously improving. We apply these same principles to the TXIT examination process (3) and always strive to make the examination an important, useful tool to our membership. Marie E. Taylor, MD, FACR Baptist Memorial Hospital East Memphis, Tennessee
241
Sandra S. Hatch, MD, FACR University of Texas Medical Branch Galveston, Texas Matthew J. Wenger, BBA Assessment and Curriculum Development Divison IT Professional Group, Inc. Vienna, Virginia Neha Vapiwala, MD John P. Plastaras, MD, PhD University of Pennsylvania Philadelphia, Pennsylvania Seth A. Rosenthal, MD, FACR, FASTRO Sutter Medical Group Sutter Cancer Center Sacramento, California Albert L. Blumberg, MD, FACR Greater Baltimore Medical Center Baltimore, Maryland http://dx.doi.org/10.1016/j.ijrobp.2014.05.001
References 1. Morris A. The radiation oncology in-training examination: An appeal for better testing. Int J Radiat Biol Oncol Phys 2013;87:443-445. 2. DIAGNOSTIC RADIOLOGY CERTIFYING EXAMINATION POLICY. American Board of Radiology. Available at: http://www. theabr.org/sites/all/themes/abr-edia/pdf/ICDRCertifyingExamPolicy. pdf. Accessed July 28, 2014. 3. Millman, J., & Greene, J. (1993). The specification and development of tests of achievement and ability. In R.L. Linn (Ed.), Educational measurement (pp. 335-366). Phoenix, AZ: Oryx Press.
ERRATUM Erratum to: Aluwini S, van Rooij PH, Kirkels WJ, Boormans JL, Kolkman-Deurloo IK, Wijnmaalen A. Bladder function preservation with brachytherapy, external beam radiation therapy, and limited surger in bladder cancer patients: Long-term results. Int J Radiat Oncol Biol Phys 2014;88:611-617. The Red Journal would like to apologize for an error in the title of this paper. The correct title should read: Bladder function preservation with brachytherapy, external beam radiation therapy, and limited surgery in bladder cancer patients: Long-term results http://dx.doi.org/10.1016/j.ijrobp.2014.05.037
Comments
Association Between White Blood Cell Count Following Radiation Therapy and Radiation Pneumonitis in Non-Small Cell Lung Cancer
International Journal of Radiation Oncology Biology Physics
of countermeasures intended to mitigate radiation-induced fibrosis after irradiation has been administered (9, 10). Keith A. Cengel, MD, PhD Charles B. Simone, II, MD Department of Radiation Oncology University of Pennsylvania Philadelphia, Pennsylvania
In Regard to Tang et al To the Editor: With great interest, we read the recent article by Tang and colleagues (1), which describes the association between radiation pneumonitis and leukocyte (white blood cell [WBC]) counts following radiation therapy. These data serve to reinforce the notion that an aberrantly robust inflammatory response may be a critical underlying factor in determining a patient’s sensitivity to radiation pneumonitis (2-4). Indeed, in studies using a Yucatan mini-pig wholebody radiation exposure model, we have observed that leukopenia resulting from increased relative dose to bone marrow is associated with a decrease in the slope of the dose-toxicity response curve for radiation pneumonitis (5). Conversely, the current analysis by Tang et al (1) presented in Figure 3 suggests that the presence of elevated WBC counts may be able to identify patients with an increased dose-pneumonitis response slope. The authors should be commended for their detailed analysis. However, critical questions remain, especially regarding the subjective nature in the diagnosis of radiation pneumonitis. Common Terminology Criteria for Adverse Events, version 3.0, for pneumonitis do not include any specific radiologic criteria, but rather these are included under the pulmonary fibrosis designation (6). From their methods, it appears the investigators used a subjective review of these multiple clinical and radiographic criteria under the heading of radiation pneumonitis, which is problematic given the unclear mechanistic nature of the linkage between radiation pneumonitis and radiation fibrosis. Given that this distinction is the underpinning of their study, it would be informative for the investigators to provide a more detailed description of these findings and criteria (7). To address the inherent difficulties in diagnosing radiation-induced lung injury, we have used an established, semi-quantitative scoring system for fibrosis in a recent study (8). We systematically evaluated radiation fibrosis in 44 consecutive patients receiving definitive radiation therapy for small cell lung cancer in our department, finding that radiation fibrosis scores at 1 year were highly predictive of long-term clinical pulmonary decline parameters such as dyspnea and decreases in pulmonary function test results. In support of the recent findings by Tang et al (1), we have analyzed the correlation between WBC levels and fibrosis in our study population and determined that patients with moderate to severe pulmonary fibrosis demonstrate similarly elevated WBC at the 3-month posteradiation therapy follow-up visit. If WBC levels are validated as a biomarker for radiation fibrosis risk, they could be highly useful in selecting patients for future trials
http://dx.doi.org/10.1016/j.ijrobp.2014.04.045
References 1. Tang C, Gomez DR, Wang H, et al. Association between white blood cell count following radiation therapy with radiation pneumonitis in non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2014;88: 319-325. 2. Ghafoori P, Marks LB, Vujaskovic Z, et al. Radiation-induced lung injury. Assessment, management, and prevention. Oncology (Williston Park) 2008;22:37-47. 3. Hill RP, Zaidi A, Mahmood J, et al. Investigations into the role of inflammation in normal tissue response to irradiation. Radiother Oncol 2011;101:73-79. 4. Stone HB, Moulder JE, Coleman CN, et al. Models for evaluating agents intended for the prophylaxis, mitigation and treatment of radiation injuries. Report of an NCI Workshop, December 3-4, 2003. Radiat Res 2004;162:711-728. 5. Wilson JM, Sanzari JK, Diffenderfer ES, et al. Acute biological effects of simulating the whole-body radiation dose distribution from a solar particle event using a porcine model. Radiat Res 2011;176: 649-659. 6. Trotti A, Colevas AD, Setser A, et al. CTCAE v3.0: Development of a comprehensive grading system for the adverse effects of cancer treatment. Semin Radiat Oncol 2003;13:176-181. 7. Mazeron R, Etienne-Mastroianni B, Pe´rol D, et al. Predictive factors of late radiation fibrosis: A prospective study in non-small cell lung cancer. Int J Radiat Oncol Biol Phys 2010;77:38-43. 8. Hertan H, Torigian DA, Xanthopoulos EP, et al. Evolution of and predictors for pulmonary fibrosis following definitive thoracic radiation therapy. Int J Radiat Oncol Biol Phys 2013;87(suppl):S522-S523. 9. DiCarlo AL, Jackson IL, Shah JR, et al. Development and licensure of medical countermeasures to treat lung damage resulting from a radiological or nuclear incident. Radiat Res 2012;177:717-721. 10. Pietrofesa R, Turowski J, Tyagi S, et al. Radiation mitigating properties of the lignan component in flaxseed. BMC Cancer 2013; 13:179.
Reliability of the ACR Radiation Oncology In-Training Exam In Regard to Morris To the Editor: The American College of Radiology (ACR) has provided the Radiation Oncology In-Training (TXIT) examination for 30 years. It offers residents an opportunity for identification of areas for improvement relative to their peers at the same level of training. It permits program directors to assess strengths and potential gaps in their programs. We appreciate the opportunity to respond to Dr Morris’ editorial (1).
Volume 90 Number 1 2014
Comments
The author claims the ACR has been silent about how scores should be used, questions whether examinations are reliable and properly validated, and perceives few published data about the psychometric performance. The examination’s validity is compared to the American Board of Radiology’s (ABR) practice analysis approach (2). The ACR provides information regarding its intended use in the packets sent yearly to program directors. The psychometric performance exceeds standards with an alpha of 91.5%. Its mean biserial coefficient, mean item difficulty, and standard deviations are within acceptable standards. The ABR examination is a criterion-referenced occupational test, and the ACR TXIT examination is a norm-referenced educational test. The ACR provides program directors with mean normreferenced scores at the national, institutional, and individual levels. In 2014, the examination scores will be incorporated into the Radiological Society of North America myPortfolio tool as well as a guide to interpreting the results. The ACR publishes recent examinations on its Website, along with rationales that include annotated bibliographies. The ACR hopes this feedback will allow residents to assess progress and build competencies, with focused study efforts guided by these data. The ACR seeks quality and excellence in all endeavors. We understand that the process of professional assessment is ongoing and continuously improving. We apply these same principles to the TXIT examination process (3) and always strive to make the examination an important, useful tool to our membership. Marie E. Taylor, MD, FACR Baptist Memorial Hospital East Memphis, Tennessee
241
Sandra S. Hatch, MD, FACR University of Texas Medical Branch Galveston, Texas Matthew J. Wenger, BBA Assessment and Curriculum Development Divison IT Professional Group, Inc. Vienna, Virginia Neha Vapiwala, MD John P. Plastaras, MD, PhD University of Pennsylvania Philadelphia, Pennsylvania Seth A. Rosenthal, MD, FACR, FASTRO Sutter Medical Group Sutter Cancer Center Sacramento, California Albert L. Blumberg, MD, FACR Greater Baltimore Medical Center Baltimore, Maryland http://dx.doi.org/10.1016/j.ijrobp.2014.05.001
References 1. Morris A. The radiation oncology in-training examination: An appeal for better testing. Int J Radiat Biol Oncol Phys 2013;87:443-445. 2. DIAGNOSTIC RADIOLOGY CERTIFYING EXAMINATION POLICY. American Board of Radiology. Available at: http://www. theabr.org/sites/all/themes/abr-edia/pdf/ICDRCertifyingExamPolicy. pdf. Accessed July 28, 2014. 3. Millman, J., & Greene, J. (1993). The specification and development of tests of achievement and ability. In R.L. Linn (Ed.), Educational measurement (pp. 335-366). Phoenix, AZ: Oryx Press.
ERRATUM Erratum to: Aluwini S, van Rooij PH, Kirkels WJ, Boormans JL, Kolkman-Deurloo IK, Wijnmaalen A. Bladder function preservation with brachytherapy, external beam radiation therapy, and limited surger in bladder cancer patients: Long-term results. Int J Radiat Oncol Biol Phys 2014;88:611-617. The Red Journal would like to apologize for an error in the title of this paper. The correct title should read: Bladder function preservation with brachytherapy, external beam radiation therapy, and limited surgery in bladder cancer patients: Long-term results http://dx.doi.org/10.1016/j.ijrobp.2014.05.037
