SURG-08. SARCOPENIA IS A PROGNOSTIC FACTOR OF 90-DAY MORTALITY AND OVERALL SURVIVAL IN ELDERLY PATIENTS WITH GLIOBLASTOMA

2021 ◽  
Vol 23 (Supplement_6) ◽  
pp. vi196-vi196
Author(s):  
Ramin Morshed ◽  
Jacob Young ◽  
Megan Casey ◽  
Elaina Wang ◽  
Manish K Aghi ◽  
...  
Keyword(s):  
Overall Survival ◽  
Radiation Therapy ◽  
Life Expectancy ◽  
Adjuvant Therapy ◽  
Elderly Patients ◽  
Tumor Resection ◽  
Preoperative Imaging ◽  
Imaging Features ◽  
Who Grade ◽  
Treatment Data

Abstract Elderly patients with glioblastoma (GBM) have worse overall prognosis compared to younger patients and are less likely to undergo tumor resection and adjuvant therapy. The goal of this study was to identify patient and treatment factors as well as preoperative imaging features associated with worse overall survival and death within 3 months of surgery in elderly GBM patients. A single-center retrospective study was conducted with patients who met the following inclusion criteria: 1) age ≥ 79 at surgery (past the average age of life expectancy), 2) underwent biopsy or resection of an IDH-wildtype WHO Grade IV GBM at the time of initial diagnosis, and 3) had no prior radiation or chemotherapy. Patient, imaging, and treatment data were collected retrospectively from the electronic medical record. Univariate and multivariate Cox proportional hazard and logistic regression analyses were performed to identify factors associated with overall survival and 90-day mortality. The cohort consisted of 110 patients with a mean age of 82.8 (range 79 to 94.1) at surgery and a median preoperative KPS of 80. Thirty-seven (33.6%) and 73 (66.4%) patients underwent biopsy and resection, respectively. Adjuvant chemo- and/or radiation therapy were used in 72.5% of cases. On multivariate analysis, age (HR 1.13 by year, p=0.01), increased masseter thickness (HR 0.88 by mm, p=0.049), adjuvant therapy (HR 0.05, p< .0001), and surgical resection rather than biopsy (HR 0.38, p=0.0007) were associated with improved survival. Decreased masseter thickness was the only preoperative factor on analysis that predicted 90-day mortality in the cohort (p=0.038). GBM patients past the average age of life expectancy still fare better when undergoing resection followed by adjuvant chemotherapy and radiation therapy. In addition to treatment factors that predict survival, smaller masseter diameter on preoperative imaging, a marker of sarcopenia, is associated with shorter survival and death within 90 days of surgery.

scholarly journals Unique Case Report of a Meningeal Sarcoma Arising during Ongoing Treatment for Progressing Intraparenchymal Glioma

2019 ◽  
Vol 2019 ◽  
pp. 1-7 ◽  
Author(s):  
Richard A. Peterson ◽  
Bhavani Kashyap ◽  
Pamala A. Pawloski ◽  
Anna C. Forsberg ◽  
Leah R. Hanson
Keyword(s):  
Radiation Therapy ◽  
Genetic Predisposition ◽  
Radiation Treatment ◽  
Tumor Resection ◽  
Tp53 Gene ◽  
World Health ◽  
High Grade ◽  
Who Grade ◽  
Li Fraumeni Syndrome ◽  
High Grade Sarcoma

Radiation-induced sarcomas in the brain are extremely rare, usually occur with an average latency of 9 years, and are associated with poor outcomes. Latency periods shorter than 1 year may indicate a genetic predisposition such as Li-Fraumeni syndrome. A 34-year-old man underwent initial tumor resection and radiation therapy for a World Health Organization (WHO) Grade II Astrocytoma. Within 6 months, the tumor recurred as WHO Grade III and was treated with temozolomide and then bevacizumab. Despite the patient’s apparent improving condition, MRI revealed new dural-based lesions 10 months after radiation therapy and identified as high-grade sarcoma. The patient resumed bevacizumab, began NovoTTF treatment for progressing glioma, and ifosfamide/doxorubicin for the sarcoma. Genetic testing revealed no pathogenic mutation in the TP53 gene. Ultimately, treatment was unsuccessful and the patient succumbed to glioma and sarcoma within 2 years of initial diagnosis. This case was unique due to the rapidly progressing glioma and sudden appearance of a high-grade sarcoma. It is unusual to have two separate intracranial primary cancers with each requiring a different chemotherapy regimen. We discuss the difficulty of simultaneously treating with separate chemotherapy regimens. It remains unclear whether the sarcoma was induced by the radiation treatment or a genetic predisposition.

scholarly journals EPID-16. COMPARATIVE ANALYSIS OF OVERALL SURVIVAL AND ADVERSE EVENTS BY ADJUVANT TREATMENT MODALITIES IN ELDERLY PATIENTS WITH GLIOBLASTOMA USING THE SEER-MEDICARE DATABASE

2019 ◽  
Vol 21 (Supplement_6) ◽  
pp. vi77-vi78
Author(s):  
Ping Zhu ◽  
Xianglin Du ◽  
Jay-Jiguang Zhu
Keyword(s):  
Overall Survival ◽  
Adjuvant Therapy ◽  
Elderly Patients ◽  
Cohort Analysis ◽  
Cox Proportional Hazards ◽  
Competing Risk ◽  
Treatment Modalities ◽  
Risk Models ◽  
Risk Of Death ◽  
Competing Risk Models

Abstract OBJECTIVES Few studies have investigated the frequency of adverse event (AE) by adjuvant therapy modalities in elderly patients with glioblastoma (GBM) in “real-world” setting. We conducted a retrospective cohort analysis to compare survival differences and incidences of AE with different treatment modalities. METHODS A total of 3100 elderly GBM patients were derived from the Surveillance, Epidemiology and End Results (SEER)-Medicare dataset (2004–2013). Adjuvant therapy modalities were either chemoradiation (CRT) followed by maintenance chemotherapy with temozolomide or RT alone. Primary outcomes include overall survival (OS) and cumulative incidences of 6-month and 1-year AEs with adjuvant therapies. Kaplan-Meier method and Cox proportional hazards regression were applied for survival analysis. Fine-Gray competing risk models were performed to estimate the risk of incident AEs over time with death as the competing risk event. RESULTS Superior OS was observed among GBM patients treated with CRT compared to RT alone (median OS: 6.9 vs. 2.9 months, P< 0.001). In multivariable Cox proportional hazard model, the risk of death was decreased by 52% for patients in the CRT group over the RT alone group (P< 0.001). Based on the multivariable competing risk models, the receipt of CRT was associated with higher risk of incident 6-month AEs with nausea/vomiting [sub-hazard ratio (SHR): 1.82, P=0.003] and constipation (SHR: 1.47, P=0.022); and 1-year AEs with neutropenia (SHR: 1.63, P=0.002), anemia (SHR: 1.64, P< 0.002), DVT (SHR: 1.25, P=0.035), seizure/epilepsy (SHR: 1.47, P=0.001), nausea/vomiting (SHR: 2.08, P< 0.001), diarrhea (SHR: 1.70, P=0.034), gastroenteritis/colitis (SHR: 2.77, P=0.024), constipation (SHR: 1.62, P=0.001), and dehydration (SHR: 1.27, P=0.020). CONCLUSION Comparing to the RT alone group, elderly GBM patients received CRT had 4-month median OS benefit, but experienced significantly higher incidences of AEs.

The Newly Developed Modified BEACOPP-Regimen (BACOPP) Is Active and Feasible in Elderly Patients with Hodgkin Lymphoma: Results of a Phase II Study of the German Hodgkin Study Group (GHSG)

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 2600-2600
Author(s):  
Horst Mueller ◽  
Lucia Nogova ◽  
Dennis A Eichenauer ◽  
Teresa Halbsguth ◽  
Hiltrud Nisters-Backes ◽  
...  
Keyword(s):  
Overall Survival ◽  
Elderly Patients ◽  
Treatment Failure ◽  
Phase Ii Study ◽  
Final Analysis ◽  
Who Grade ◽  
Kaplan Meier ◽  
Advanced Stages ◽  
Who Grade Iii ◽  
Grade Iii

Abstract Background: Approximately 20% of patients diagnosed with Hodgkin lymphoma (HL) are more than 60 years of age. These elderly patients still have a poor prognosis, especially when presenting with advanced stages and higher age. The main reason is underdosing of treatment, which is due to reduced tolerability of chemotherapy and age-related comorbidities. In the GHSG experience, elderly patients in the HD9 trial did not profit from the BEACOPP regimen in terms of overall survival, though a better HL specific freedom from treatment failure was achieved as compared to COPP/ABVD. Thus, the GHSG has developed the BACOPP regimen (bleomycin, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone), in which etoposide was omitted to improve tolerability. Further modifications were a 1 week pretreatment phase with vincristine and prednisone, a limitation of vincristine in patients older than 65 years, an increase of the anthracyclines dose, and concomitant application of erythropoietin. Here we report on the final analysis of this multi-center phase II study for elderly patients. Methods: Between 2004 and 2005, 65 patients with HL in intermediate or advanced stages aged between 60 and 75 years were recruited. Treatment consisted of 6 cycles BACOPP in patients achieving a complete remission (CR) after 4 cycles or 8 cycles BACOPP in case of PR (partial remission) after 4 cycles. The primary endpoints were protocol adherence and response rates. Secondary endpoints included WHO grade III/IV toxicities, Kaplan Meier estimates of progression free survival (PFS), freedom from treatment failure (FFTF), and overall survival (OS). Results: Sixty patients (92%) were eligible for the final analysis. The majority of treatment courses (75%) were administered according to protocol. However, there was a tendency towards reduced dosing in cycles 5 to 8, especially for patients who had reached a CR after 4 cycles of BACOPP. In total, 51 patients showed CR/CRu (85%), 2 PR (3%) and 4 progression of disease (7%). Survival estimates and their 95% confidence intervals are shown in table 1. Table 1. Kaplan-Meier rates and 95% confidence intervals (CI) for FFTF, PFS and OS. time point rate (%) CI (95%) FFTF 12 months 73 61–84 24 months 67 55–79 PFS 12 months 75 64–86 24 months 68 56–80 OS 12 months 85 76–94 24 months 76 65–87 WHO grade III–IV toxicities were documented in 52 patients (87%). With a median observation time of 33 months, 18 deaths (30%) have been observed. Seven therapy associated fatal outcomes were documented. Conclusion: The new BACOPP regimen developed for elderly HL patients shows a high CR rate (85%). The FFTF rate at 2 years is within the range known from other schedules in this patient cohort. Overall, the regimen is feasible, but the therapy-associated death rate was high in our patient cohort. Thus, further studies and new approaches are still needed to substantially improve the outcome of elderly patients with early unfavorable or advanced stage HL.

scholarly journals Evaluation of Survival, Recurrence Patterns and Adjuvant Therapy in Surgically Staged High-Grade Endometrial Cancer with Retroperitoneal Metastases

Cancers ◽  
2021 ◽  
Vol 13 (9) ◽  
pp. 2052
Author(s):  
Jennifer McEachron ◽  
Lila Marshall ◽  
Nancy Zhou ◽  
Van Tran ◽  
Margaux J. Kanis ◽  
...  
Keyword(s):  
Overall Survival ◽  
Radiation Therapy ◽  
Endometrial Cancer ◽  
Adjuvant Therapy ◽  
Clear Cell ◽  
High Grade ◽  
Stage Iiic ◽  
Treatment Delays ◽  
Recurrence Patterns ◽  
Grade 3

Background: We seek to evaluate the difference in recurrence patterns and survival among stage IIIC high-grade endometrial cancer treated with surgery followed by adjuvant chemotherapy alone, radiation therapy alone, or both (chemoradiation). Methods: A multicenter retrospective analysis of surgically staged IIIC HGEC receiving adjuvant therapy was conducted. HGEC was defined as grade 3 endometrioid adenocarcinoma, serous, clear cell and carcinosarcoma. Differences in the frequency of recurrence sites and treatment delays were identified using Pearson’s χ2 test. Progression-free survival (PFS) and overall survival (OS) were calculated using Kaplan–Meier estimates. Results: A total of 155 patients were evaluable: 41.9% carcinosarcoma, 36.8% serous, 17.4% grade 3 and 3.9% clear cell. Of these, 67.1% received chemoradiation, 25.8% received chemotherapy and 7.1% received radiation therapy. There was no difference in the frequency of treatment delays between regimens (p = 0.571). There was a trend towards greater retroperitoneal recurrence with chemotherapy (25.9%) versus chemoradiation (8.4%) and radiation therapy (7.7%) (p = 0.252). Grade 3 tumors had improved progression-free and overall survival (26 and 42 months, respectively) versus serous (17 and 30 months, respectively), carcinosarcoma (14 and 24 months, respectively) and clear cell (24 and 30 months respectively) (p = 0.002, p < 0.001). Overall, chemoradiation was superior to chemotherapy and radiation therapy in PFS (p < 0.001) and OS (p < 0.001). Upon multivariate analysis, only histology and receipt of chemoradiation were independent predictors of survival. Conclusion: The majority of stage IIIC high-grade endometrial carcinomas recurred. Chemoradiation was associated with improved survival and less retroperitoneal recurrence. Grade 3 tumors demonstrated improved survival versus other histologies regardless of adjuvant treatment modality.

scholarly journals COMPARISON OF THE EFFECTIVENESS OF PROTON AND PHOTON THERAPY IN PATIENTS WITH BRAIN TUMORS

2021 ◽  
Vol 20 (2) ◽  
pp. 127-135
Author(s):  
V. A. Solodky ◽  
T. R. Izmailov ◽  
P. V. Polushkin
Keyword(s):  
Quality Of Life ◽  
Overall Survival ◽  
Radiation Therapy ◽  
General Information ◽  
Photon Radiation ◽  
Radiation Toxicity ◽  
Who Grade ◽  
Huge Impact ◽  
Radiation Induced

Owing to the development of molecular genetics, the role of radiation therapy and chemotherapy in treatment of patients with glioma (WHO Grade I–IV) has become more understandable. The overall survival among glioma patients has increased. As overall survival increases, oncologists are more likely to detect manifestations of late radiation toxicity that has a huge impact on Quality of Life in patients who have undergone radiation therapy in the past. In this regard, the question of finding more adequate radiation therapy techniques remains relevant. photon radiation therapy is the standard method; however, considering dosimetric advantages of proton therapy over photon therapy, its widespread use can potentially lead to the increased overall survival, decreased number of late radiation-induced complications and improved quality of life in the post-radiation period. This article presents some comparative characteristics of proton and photon radiation therapy in patients with gliomas (WHO Grade I–IV). dosimetry characteristics of protons in tissues were compared, data showing differences in survival of patients treated with photons versus patients treated with protons were presented, and general information on early and late  radiation-induced toxicity arising from the treatment by these methods was disclosed.

Effect of radiation on outcome of types II and III PPB: A report from the International Pleuropulmonary Blastoma Registry.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 9521-9521 ◽  
Author(s):  
Gretchen M Williams ◽  
John R. Priest ◽  
Marsha J Finkelstein ◽  
Anne Harris ◽  
Leslie Ann Doros ◽  
...  
Keyword(s):  
Overall Survival ◽  
Radiation Therapy ◽  
Prognostic Significance ◽  
Tumor Resection ◽  
Lung Neoplasm ◽  
Pleuropulmonary Blastoma ◽  
Type I ◽  
Tumor Type ◽  
Type Ii ◽  
Type Iii

9521 Background: Pleuropulmonary blastoma (PPB) is a rare dysembryonic lung neoplasm of early childhood with progression from a purely cystic (Type I) lesion to a solid high-grade sarcoma Type III (T-III), or a mixed solid/cystic stage Type II (T-II). Surgery and chemotherapy are required for T-II and T-III PPB, but the benefit of radiation therapy for T-II and T-III PPB is debated and is being evaluated in this study. Methods: This is a retrospective analysis of central pathology-reviewed Types II and III PPB from the IPPBR. Treatments were chosen by physician, were not randomized, and included surgery and chemotherapy. The outcome of patients treated with upfront radiation (before progression or relapse) was compared to patients who did not receive radiation. Event-free survival (EFS) and overall survival (OS) were determined to last follow-up, using the Kaplan-Meier analysis, with log-rank test. Results: Outcome for 212 patients (117 Type-II and 95 Type III) was significantly better for T-II than T-III: EFS for T-II was 68.1% vs. T-III 45.7% (P=0.002), and OS for T-II was 75.2% vs. T-III 57.9% (p=0.01). Excluding patients with incomplete therapy information, 174 were treated with surgery and chemotherapy. Of these 44 (25%) also received radiation therapy; 130 patients did not. The table below shows comparison of radiated vs. non-radiated. Radiation provided no additional survival benefit, overall or by tumor Type. Multivariate analysis showed that gender and extent of primary tumor resection (biopsy vs. gross total resection) had no effect on outcome, however T-II vs. T-III retained prognostic significance. Conclusions: For this collection of advanced-type PPB, outcome is significantly better for T-II than T-III. For patients treated initially with surgery and chemotherapy, adding radiation therapy offered no improvement in event-free or overall survival. Limitations of this study include its retrospective nature and non-uniform treatment regimens. [Table: see text]

Preoperative Imaging Features are Associated with Surgical Complications Following Carotid Body Tumor Resection

2015 ◽  
Vol 39 (8) ◽  
pp. 2084-2089 ◽  
Author(s):  
David M. Straughan ◽  
Vladimir K. Neychev ◽  
Samira M. Sadowski ◽  
Ryan J. Ellis ◽  
Francine Thomas ◽  
...  
Keyword(s):  
Carotid Body ◽  
Surgical Complications ◽  
Tumor Resection ◽  
Carotid Body Tumor ◽  
Preoperative Imaging ◽  
Imaging Features

scholarly journals The role of revision surgery and adjuvant therapy following subtotal resection of osteosarcoma of the spine: a systematic review with meta-analysis

2017 ◽  
Vol 27 (1) ◽  
pp. 97-104 ◽  
Author(s):  
Ganesh M. Shankar ◽  
Michelle J. Clarke ◽  
Tamir Ailon ◽  
Laurence D. Rhines ◽  
Shreyaskumar R. Patel ◽  
...  
Keyword(s):  
Systematic Review ◽  
Overall Survival ◽  
Radiation Therapy ◽  
Adjuvant Therapy ◽  
Revision Surgery ◽  
Meta Analysis ◽  
Adjuvant Radiation ◽  
En Bloc ◽  
Adjuvant Radiation Therapy

OBJECTIVEPrimary osteosarcoma of the spine is a rare osseous neoplasm. While previously reported retrospective studies have demonstrated that overall patient survival is impacted mostly by en bloc resection and chemotherapy, the continued management of residual disease remains to be elucidated. This systematic review was designed to address the role of revision surgery and multimodal adjuvant therapy in cases in which en bloc excision is not initially achieved.METHODSA systematic literature search spanning the years 1966 to 2015 was performed on PubMed, Medline, EMBASE, and Web of Science to identify reports describing outcomes of patients who underwent biopsy alone, neurological decompression, or intralesional resection for osteosarcoma of the spine. Studies were reviewed qualitatively, and the clinical course of individual patients was aggregated for quantitative meta-analysis.RESULTSA total of 16 studies were identified for inclusion in the systematic review, of which 8 case reports were summarized qualitatively. These studies strongly support the role of chemotherapy for overall survival and moderately support adjuvant radiation therapy for local control. The meta-analysis revealed a statistically significant benefit in overall survival for performing revision tumor debulking (p = 0.01) and also for chemotherapy at relapse (p < 0.01). Adjuvant radiation therapy was associated with longer survival, although this did not reach statistical significance (p = 0.06).CONCLUSIONSWhile the initial therapeutic goal in the management of osteosarcoma of the spine is neoadjuvant chemotherapy followed by en bloc marginal resection, this objective is not always achievable given anatomical constraints and other limitations at the time of initial clinical presentation. This systematic review supports the continued aggressive use of revision surgery and multimodal adjuvant therapy when possible to improve outcomes in patients who initially undergo subtotal debulking of osteosarcoma. A limitation of this systematic review is that lesions amenable to subsequent resection or tumors inherently more sensitive to adjuvants would exaggerate a therapeutic effect of these interventions when studied in a retrospective fashion.

Glioblastoma therapy in the elderly and the importance of the extent of resection regardless of age

2012 ◽  
Vol 116 (2) ◽  
pp. 357-364 ◽  
Author(s):  
Ági Oszvald ◽  
Erdem Güresir ◽  
Matthias Setzer ◽  
Hartmut Vatter ◽  
Christian Senft ◽  
...  
Keyword(s):  
Overall Survival ◽  
Prognostic Factor ◽  
Elderly Patients ◽  
Clinical Status ◽  
Combined Treatment ◽  
Tumor Resection ◽  
Extent Of Resection ◽  
Karnofsky Performance Scale ◽  
Extensive Resection ◽  
Younger Patients

Object The objective of this study was to analyze whether age influences the outcome of patients with glioblastoma and whether elderly patients with glioblastoma can tolerate the same aggressive treatment as younger patients. Methods Data from 361 consecutive patients with newly diagnosed cerebral glioblastoma (2000–2006) who underwent regular follow-up evaluation from initial diagnosis until death were prospectively entered into a database. Patients underwent resection (complete, subtotal, or partial) or biopsy, depending on tumor size, location, and Karnofsky Performance Scale score. Following surgery, all patients underwent adjuvant treatment consisting of radiotherapy, chemotherapy, or combined treatment. Patients older than 65 years of age were defined as elderly (146 total). Results Two hundred thirty-four patients underwent tumor resection (complete 26%, subtotal 29%, and partial 45%). One hundred twenty-seven underwent biopsy. Mean patient age was 61 years, and overall survival was 11.6 ± 12.1 months. The overall survival of elderly patients (9.1 ± 11.6 months) was significantly lower than that of younger patients (14.9 ± 16.7 months; p = 0.0001). Stratifying between resection or biopsy, age was a negative prognostic factor in patients undergoing biopsy (4.0 ± 7.1 vs 7.9 ± 8.7 months; p = 0.007), but not in patients undergoing tumor resection (13.0 ± 8.5 vs 13.3 ± 14.5 months; p = 0.86). Survival of elderly patients undergoing complete tumor resection was 17.7 ± 8.1 months. Conclusions In this series of patients with glioblastoma, age was a prognostic factor in patients undergoing biopsy, but not in patients undergoing resection. Tumor location and patient clinical status may prohibit extensive resection, but resection should not be withheld from patients only on the basis of age. In elderly patients with glioblastoma, undergoing resection to the extent feasible, followed by adjuvant therapies, is warranted.

scholarly journals The Impact of Radiation Therapy Variables on Pediatric High-Grade Glioma Outcomes: A National Cancer Database Analysis

2021 ◽  
Author(s):  
Christopher Williamson ◽  
Shayla Williamson ◽  
Renjian Jiang ◽  
Lisa Sudmeier ◽  
Natia Esiashvili ◽  
...  
Keyword(s):  
Overall Survival ◽  
Radiation Therapy ◽  
Private Insurance ◽  
Multivariable Analysis ◽  
High Grade Glioma ◽  
National Cancer Database ◽  
High Grade ◽  
Who Grade ◽  
The Impact ◽  
Pediatric High Grade Glioma

Abstract Purpose Pediatric high-grade glioma (HGG) is a devastating disease with a poor prognosis. The purpose of this analysis is to evaluate the impact of Radiation Therapy (RT) variables on outcomes of pediatric HGG patients in the National Cancer Database (NCDB). Methods The NCDB was used to select patients age < 22 with histologically proven WHO Grade III and IV gliomas treated with ≥ 50Gy and < 76Gy RT between 2004 and 2013. RT variables including RT dose, timing between diagnosis and RT initiation (< 4 weeks, 4–6 weeks, or > 6 weeks), and RT modality were analyzed along with baseline demographic, tumor and treatment variables to assess the impact on overall survival in univariate and multivariable analyses. Results 498 pediatric HGG patients were included. Histologies included glioblastoma (30%), astrocytoma (55%), oligogendroglioma (5%) and gliomas not otherwise specific (10%). The median RT dose was 59.4 Gy (SD 2.9 Gy) starting a median of 4.4 weeks from diagnosis (SD 2.5 weeks). Median follow-up was 19.6 months with 1- and 3-year OS of 78.4% and 40.4%, respectively. On Multivariable analysis, female gender, older age, and private insurance remained independently associated with lower rate of overall death. Radiation initiation ≤ 4 weeks from diagnosis, and glioblastoma histology were significantly associated with higher rate of overall death. There was no relationship between radiation dose or whether radiation was delivered with proton or photon therapy and overall survival. Conclusions Outcomes for pediatric HGG are poor. Early initiation of RT within 4 weeks from diagnosis was negative associated with overall survival and may be related to unknown prognostic factors.

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