Paulina Gutkin

All Publications

• Integrating Audiovisual Immersion Into Pediatric Radiation Therapy Across Multiple Centers: Methodology, Timeliness, and Cost of the Audiovisual-Assisted Therapeutic Ambience in Radiation Therapy Prospective Multi-Institutional Trial ADVANCES IN RADIATION ONCOLOGY Oh, J., Skinner, L., Gutkin, P. M., Jiang, A., Donaldson, S. S., Loo Jr, B. W., Wang, Y., Ewongwo, A., Bredfeldt, J. S., Breneman, J. C., Constine, L. S., Faught, A. M., Haas-Kogan, D., Holmes, J. A., Krasin, M., Larkin, C., Marcus, K. J., Maxim, P. G., McClelland III, S., Murphy, B., Palmer, J. D., Perkins, S. M., Shen, C. J., Terezakis, S., Bush, K., Hiniker, S. M. 2024; 9 (10)

  View details for DOI 10.1016/j.adro.2024.101589

  View details for Web of Science ID 001313488600001

• Integrating Audiovisual Immersion Into Pediatric Radiation Therapy Across Multiple Centers: Methodology, Timeliness, and Cost of the Audiovisual-Assisted Therapeutic Ambience in Radiation Therapy Prospective Multi-Institutional Trial. Advances in radiation oncology Oh, J., Skinner, L., Gutkin, P. M., Jiang, A., Donaldson, S. S., Loo, B. W., Wang, Y. P., Ewongwo, A., Bredfeldt, J. S., Breneman, J. C., Constine, L. S., Faught, A. M., Haas-Kogan, D., Holmes, J. A., Krasin, M., Larkin, C., Marcus, K. J., Maxim, P. G., McClelland, S., Murphy, B., Palmer, J. D., Perkins, S. M., Shen, C. J., Terezakis, S., Bush, K., Hiniker, S. M. 2024; 9 (10): 101589

  Abstract

  The Audiovisual-Assisted Therapeutic Ambience in Radiotherapy (AVATAR) trial was a prospective multicenter study (NCT03991156) examining the combination of video immersion with radiation therapy and was successfully conducted through the collaboration of pediatric radiation oncology teams at 10 institutions independent of any pre-existing consortium. We sought to analyze and report the methodology of trial conception and development, process map, and cost.The study enrolled patients aged 3 to 10 years preparing to undergo radiation therapy, integrated the combination of AVATAR-based video immersion with radiation therapy at each institution, and offered AVATAR use as an alternative to anesthesia, with rates of anesthesia use and outcomes of serial standardized anxiety and quality-of-life assessments assessed among the 81 children enrolled. A process map was created based on the trial timeline with the following components: study development time (time from conception of the trial to the accrual of the first patient, including design phase, agreement and approval phase, and site preparation phase), and accrual duration time (time from the first to last accrual). Costs and institutional success rates were calculated.Time from inception of study to last accrual was 3.6 years (1313 days). The study development time was 417 days (31.7%), and accrual duration time was 896 days (68.3%), with the final 50% of accrual occurring in <6 months. Equipment cost was approximately $550 per institution and was covered by funding from the lead study institution. All 10 centers were successful with AVATAR implementation, defined as ≥50% of patients able to avoid anesthesia with the use of AVATAR, including centers with both photon and proton therapy.This report elaborates on the methodology and timeline of trial conception and development using data from a previously published supportive care study combining video immersion with radiation therapy among 10 cooperating pediatric oncology institutions. It highlights the potential for multicenter collaborations on prospective trials integrating supportive care therapies with radiation therapy.

  View details for DOI 10.1016/j.adro.2024.101589

  View details for PubMedID 39309703

  View details for PubMedCentralID PMC11415686

• In the Era of pass/fail: Medical student perceptions on optimizing their surgical residency applications. American journal of surgery Gutkin, P. M., Botros, M., Kasper, L., Solovieva, I., Gomes, I., Dream, S. 2024: 115951

  Abstract

  It is unclear how changes to the 2023-2024 Electronic Residency Application Service (ERAS) application will impact future applicants. We investigate students' perceptions about applying to residency during this transition period.An anonymous electronic survey was sent to medical students through social media of a women's surgical society. Questions reflected aspects of the ERAS application.There were 415 responses, with 68 ​% planning to apply into surgical specialties (SS) and 17 ​% into non-surgical specialties (NSS). Compared with the NSS group, SS students reported decreased confidence in successfully matching, less attainable applicant expectations, and increased personal sacrifices to pursue their residency of interest. Students interested in Plastic and Reconstructive Surgery (PRS) placed 3-times more importance on the number of publications than General Surgery students. Away rotations were rated significantly more important for Otolaryngology, Orthopaedic, and PRS students.Students applying into surgical residencies experience unique stressors. Values among SS students differed across surgical subspecialties in preparation for the match. Further investigation characterizing the relationship between these values and characteristics of successful resident applicants is warranted.

  View details for DOI 10.1016/j.amjsurg.2024.115951

  View details for PubMedID 39271428

• AVATAR 2.0: next level communication systems for radiotherapy through face-to-face video, biofeedback, translation, and audiovisual immersion. Frontiers in oncology Schulz, J. B., Zalavari, L., Gutkin, P., Jiang, A., Wang, Y., Gibson, C., Garza, A., Bush, K. K., Wang, L., Donaldson, S. S., Loo, B. W., Hiniker, S. M., Skinner, L. 2024; 14: 1405433

  Abstract

  Purpose: This paper discusses an advanced version of our audiovisual-assisted therapeutic ambience in radiotherapy (AVATAR) radiolucent display systems designed for pediatric radiotherapy, enabling anesthesia-free treatments, video communication, and biofeedback. The scope of the AVATAR system is expanded here in two major ways: (i) through alternative mounting systems to accommodate a broader range of radiotherapy machines (specifically to fit robotic-arm and toroidal geometry photon radiotherapy and proton radiotherapy systems) and (ii) through additional hardware to provide video-calling, optimized audio for clear communication, and combined video inputs for biofeedback, translation, and other advanced functionalities.Methods and materials: Because robustness requires strong parts and radio-transparency requires thin, light parts, three-dimensional printing was used to rapidly prototype hollow structures and to iteratively improve robustness. Two system designs were made: one that mounts superior and another that mounts inferior to the patient's head. Radiation dose measurements and calculations were conducted to assess dose perturbations at surface and depth due to the screen.Results: For 6-MV volumetric modulated arc therapy (VMAT) plans, with and without the screen, the mean and maximum dose differences inside the planning target volume were 0.2% and 2.6% of the 200 cGy prescription, respectively. For a single static beam through the screen, the maximum measured excess surface dose was 13.4 ± 0.5%, and the largest measured dose attenuation at 5-cm water-equivalent depth was 2.1 ± 0.2%. These percentages are relative to the dose without the screen at those locations.Conclusions: The radiolucent screen systems provided here are shown to give minimal dosimetric effects on megavoltage VMAT photon treatments. For static beams, however, surface dose effects should be considered when these beams pass through the thickest components of the screen. Design files are also provided.

  View details for DOI 10.3389/fonc.2024.1405433

  View details for PubMedID 39439954

• Feasibility of the Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) system for anesthesia avoidance in pediatric patients: A multicenter trial. International journal of radiation oncology, biology, physics Gutkin, P. M., Skinner, L., Jiang, A., Donaldson, S. S., Loo, B. W., Oh, J., Wang, Y. P., von Eyben, R., Snyder, J., Bredfeldt, J. S., Breneman, J. C., Constine, L. S., Faught, A. M., Haas-Kogan, D., Holmes, J. A., Krasin, M., Ccls, C. L., Marcus, K. J., Maxim, P. G., Iii, S. M., Murphy, B., Palmer, J. D., Perkins, S. M., Shen, C. J., Terezakis, S., Bush, K., Hiniker, S. M. 2023

  Abstract

  The AVATAR system was the first published radiotherapy (RT) compatible system to reduce the need for pediatric anesthesia through video-based distraction. We evaluate the feasibility of AVATAR implementation and effects on anesthesia use, quality of life (QoL), and anxiety in a multicenter pediatric trial.Pediatric patients 3-10 years of age preparing to undergo RT at 10 institutions were prospectively enrolled. Children able to undergo at least one fraction of RT using AVATAR without anesthesia were considered successful (S). Patients requiring anesthesia for their entire treatment course were non-successful (NS). PedsQL3.0 Cancer Module survey (PedsQL) assessed QoL and was administered to the patient and guardian at RT simulation, midway through RT, and final treatment. The modified Yale Preoperative Assessment Survey Short Form (mYPAS) assessed anxiety and was performed at the same three timepoints. Success was evaluated using Chi-square test. PedsQL and mYPAS scores were assessed using mixed effects models with time points evaluated as fixed effects and a random intercept on the subject.Eighty-one children were included; median age was 7 years. AVATAR was successful at all 10 institutions and with photon and proton RT. There were 63 (78%) S patients; anesthesia was avoided for a median of 20 fractions per patient. Success differed by age (p=0.04) and private versus public insurance (p<0.001). Both patient (p=0.008) and parent (p=0.006) PedsQL scores significantly improved over the course of RT for patients ages 5-7. Anxiety in the treatment room decreased for both S and NS patients over RT course (p<0.001), by age (p<0.001) and by S versus NS patients (p<0.001).In this 10-center prospective trial, anesthesia avoidance with AVATAR was 78% in children age 3-10 years, higher than among age-matched historical controls (49%, p<0.001). AVATAR implementation is feasible across multiple institutions and should be further studied and made available to patients who may benefit from video-based distraction.

  View details for DOI 10.1016/j.ijrobp.2023.03.063

  View details for PubMedID 37001762

• Stereotactic body radiotherapy for metastatic sarcoma to the lung: adding to the arsenal of local therapy. Radiation oncology (London, England) Gutkin, P. M., Gore, E., Charlson, J., Neilson, J. C., Johnstone, C., King, D. M., Hackbarth, D. A., Wooldridge, A., Mannem, R., Bedi, M. 2023; 18 (1): 42

  Abstract

  Conventional treatment of pulmonary metastatic sarcoma primarily involves surgery, with systemic therapy added in select patients. However, broader applications of radiation therapy techniques have prompted investigation into the use of stereotactic body radiotherapy (SBRT) for treatment of metastatic sarcoma, an attractive non-invasive intervention with potential for lower rates of adverse events than surgery. Current data are limited to retrospective analyses. This study analyzed 2-year local control and overall survival and adverse events in patients prospectively treated with SBRT to pulmonary sarcoma metastases.Patients prospectively treated with SBRT to the lung for biopsy-proven metastatic sarcoma at a single institution from 2010 to 2022 were included. SBRT dose/fractionation treatment regimens ranged from 34 to 54 Gy in 1-10 fractions using photons. Local recurrence, local progression-free survival (LPFS) and overall survival (OS) were calculated from the end of SBRT. Univariable analysis (UVA) was performed using the log-rank test. Multivariable analysis (MVA) was performed using the Cox proportional hazards model. Adverse events due to SBRT were graded based on the Common Terminology Criteria for Adverse Events, version 4.0.Eighteen patients with metastatic sarcoma were treated to 26 pulmonary metastases. The median local progression-free survival was not met. The median overall survival was not met. The local control rate at 2 years was 96%. 2-year LPFS was 95.5% and OS was 74%. Three patients (16.7%) developed grade 1 adverse events from SBRT. There were no adverse events attributed to radiation that were grade 2 or higher.We report prospective data demonstrating that SBRT for sarcoma pulmonary metastases affords a high rate of local control and low toxicity, consistent with prior sarcoma SBRT retrospective data. This study adds to the wealth of information on SBRT in a radioresistant tumor. Though largely limited to retrospective reviews, current data indicate high rates of local control with favorable toxicity profiles. Therefore, SBRT for pulmonary sarcoma metastases may be considered for properly selected patients.

  View details for DOI 10.1186/s13014-023-02226-3

  View details for PubMedID 36859309

  View details for PubMedCentralID PMC9976442

• Local control outcomes using stereotactic body radiotherapy or surgical resection for metastatic sarcoma. International journal of radiation oncology, biology, physics Gutkin, P. M., von Eyben, R., Chin, A., Donaldson, S. S., Oh, J., Jiang, A., Ganjoo, K. N., Avedian, R. S., Bruzoni, M., Steffner, R. J., Moding, E. J., Hiniker, S. M. 2022

  Abstract

  Traditional management of metastatic sarcoma primarily relies on systemic therapy, with surgery often used for tumor control. We analyzed the rates of recurrence, overall survival, and treatment complications in patients undergoing either surgical resection or stereotactic body radiotherapy (SBRT) for metastatic sarcoma of the bone and/or soft tissue.The records of patients with metastatic sarcoma between 2009-2020 were reviewed. Local recurrence (LR) was defined as tumor growth or recurrence at the tumor site. Cumulative local recurrence incidence was analyzed accounting for the competing risk of death, and groups were compared using the Gray test. Overall survival (OS) was assessed using the Kaplan Meier method and log-rank test. Hazard ratios were determined using Cox proportional test.A total of 525 metastatic lesions in 217 patients were analyzed. Mean age was 57 years (range 4-88). The lung was the predominant site treated (50%), followed by intra-abdominal (13%), and soft-tissue (11%). Two-year cumulative incidences of LR for surgery and SBRT were 14.8% (95% confidence interval [CI], 11.6-18.5) and 1.7% (95% CI, 0.1-8.2), respectively (p=0.003). LR occurred in 72/437 (16.5%) tumors treated with surgery and 2/88 (2.3%) tumors treated with SBRT. Adjusted hazard ratio for LR of lesions treated surgically was 11.5 (p=0.026) when controlled for tumor size and tumor site. Median OS was 29.8 months (95% CI, 25.6-40.9). There were 47 surgical complications of a total of 275 procedures (18%). Of 58 radiation treatment courses, radiation-related toxicity was reported during the treatment of 7 lesions (12%), and none were higher than grade 2.We observed excellent local control among patients selected for treatment with SBRT for metastatic sarcoma, with no evidence of increase in LR following SBRT when compared to surgical management. Further investigation is necessary to better define the most appropriate local control strategies for metastatic sarcoma.

  View details for DOI 10.1016/j.ijrobp.2022.05.017

  View details for PubMedID 35643255

• Delays in Care Associated With Non-English-Speaking Patients With Breast Cancer. Journal of the National Comprehensive Cancer Network : JNCCN Balazy, K. E., Benitez, C. M., Gutkin, P. M., Jacobson, C. E., von Eyben, R., Horst, K. C. 2021

  Abstract

  BACKGROUND: Breast cancer care requires coordination between multiple diagnostic and treatment modalities. Disparities such as age, race/ethnicity, and socioeconomic status are associated with delays in care. This study investigates whether primary language is associated with delays in breast cancer diagnosis and treatment before and through radiotherapy (RT).PATIENTS AND METHODS: This study was an institutional retrospective matched-cohort analysis of women treated with breast RT over 2 years. A total of 65 non-English-speaking (NES) patients were matched with 195 English-speaking (ES) patients according to stage, age, and chemotherapy delivery. Key time intervals along the breast cancer care path from initial findings through RT were recorded. Data were analyzed in a mixed model with matching as the random effect. The impact of race and insurance status was analyzed in addition to language.RESULTS: Significant delays were found for NES patients, which varied by race. NES Latina patients experienced the longest delay, with a mean total care-path time of 13.53 months (from initial findings to end of RT) versus 8.18 months for all ES patients (P<.0001). Specifically, their mean total care-path time was 5.97 months longer than that of ES Latina patients (P=.001) and 5.80 months longer than that of ES White patients (P<.0001). In addition, NES Latina patients had a significantly longer total care-path time than NES patients of other races/ethnicities (P=.001). Delays were specifically seen between initial clinical or radiographic findings and diagnostic mammogram (P=.001) and between biopsy and resection (P=.044). Beyond language, race/ethnicity was itself associated with delays between resection and start of RT (P=.032) and between start and end of RT (P=.022).CONCLUSIONS: Language is associated with pre-RT delays in breast cancer care, especially for NES Latina patients. Delays are most pronounced before diagnostic mammograms, but they also exist before resection and RT. Future work should target NES patients to assist their progress along the care path.

  View details for DOI 10.6004/jnccn.2020.7797

  View details for PubMedID 34689120

• Impact of Insurance on Stage of Breast Cancer Presentation for Different Races and Ethnicities. JCO oncology practice Balazy, K. E., Benitez, C. M., Gutkin, P. M., Karl, J. J., Jacobson, C. E., von Eyben, R., Horst, K. C. 2021; 17 (5): e603–e613

  Abstract

  PURPOSE: Survival in breast cancer is largely stage-dependent. Lack of insurance and Medicaid have been associated with later-stage breast cancer, but it is unknown to what degree this association varies by race or ethnicity.METHODS: We conducted a retrospective single-institution cohort analysis of women undergoing breast radiotherapy from 2012 to 2017 (n = 1,019). Patients were categorized as having private insurance (n = 540), Medicare (n = 332), Medicaid (n = 122), or self-pay (n = 25). Ordinal logistic regression analysis identified variables associated with later-stage presentation, including age, race or ethnicity, insurance, the interaction between insurance and race or ethnicity, body mass index, education, and language.RESULTS: The association between insurance and breast cancer stage varied on the basis of a patient's race or ethnicity (P = .0114). White and Asian patients with Medicaid had significantly higher odds of later-stage breast cancer than those with private insurance (White odds ratio [OR], 2.10; 95% CI, 1.02 to 4.34; Asian OR, 3.22; 95% CI, 1.56 to 6.67). However, the inverse was true for Hispanic patients who had lower odds of later-stage disease with Medicaid than private insurance (OR, 0.36; 95% CI, 0.16 to 0.90). Hispanic patients with Medicaid had lower odds than either White or Asian patients with Medicaid. These findings persisted across all ages.CONCLUSION: The association between insurance and later-stage presentation is significantly influenced by race or ethnicity. Medicaid was generally associated with later-stage breast cancer diagnosis, but this was not true across all races and ethnicities. Although White and Asian patients with Medicaid presented with later stage, Hispanic patients fared better with Medicaid than private insurance. Future work should investigate how Medicaid is successfully targeting Hispanic patients in breast cancer care.

  View details for DOI 10.1200/OP.20.00950

  View details for PubMedID 33974824

• Use of Audiovisual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) for Anesthesia Avoidance in a Pediatric Patient With Down Syndrome. Advances in radiation oncology Gutkin, P. M., Donaldson, S. S., Skinner, L., Callejas, M., Cimino, J., Lore, J., Bush, K., Hiniker, S. M. 2021; 6 (2): 100637

  View details for DOI 10.1016/j.adro.2020.100637

  View details for PubMedID 33732961

• Telemedicine in Radiation Oncology: Is It Here to Stay? Impacts on Patient Care and Resident Education. International journal of radiation oncology, biology, physics Gutkin, P. M., Prionas, N. D., Minneci, M. O., Allen, E. 3., Balazy, K. E., Rahimy, E., Chang, D. T., Horst, K. C. 2020; 108 (2): 416–20

  Abstract

  PURPOSE: Telemedicine was rapidly and ubiquitously adopted during the COVID-19 pandemic. However, there are growing discussions as to its role postpandemic.METHODS AND MATERIALS: We surveyed patients, radiation oncology (RO) attendings, and RO residents to assess their experience with telemedicine. Surveys addressed quality of patient care and utility of telemedicine for teaching and learning core competencies. Satisfaction was rated on a 6-point Likert-type scale. The quality of teaching and learning was graded on a 5-point Likert-type scale, with overall scores calculated by the average rating of each core competency required by the Accreditation Council for Graduate Medical Education (range, 1-5).RESULTS: Responses were collected from 56 patients, 12 RO attendings, and 13 RO residents. Patient feedback was collected at 17 new-patient, 22 on-treatment, and 17 follow-up video visits. Overall, 88% of patients were satisfied with virtual visits. A lower proportion of on-treatment patients rated their virtual visit as "very satisfactory" (68.2% vs 76.5% for new patients and 82.4% for follow-ups). Only 5.9% of the new patients and none of the follow-up patients were dissatisfied, and 27% of on-treatment patients were dissatisfied. The large majority of patients (88%) indicated that they would continue to use virtual visits as long as a physical examination was not needed. Overall scores for medical training were 4.1 out of 5 (range, 2.8-5.0) by RO residents and 3.2 (range, 2.0-4.0) by RO attendings. All residents and 92% of attendings indicated they would use telemedicine again; however, most indicated that telemedicine is best for follow-up visits.CONCLUSIONS: Telemedicine is a convenient means of delivering care to patients, with some limitations demonstrated for on-treatment patients. The majority of both patients and providers are interested in using telemedicine again, and it will likely continue to supplement patient care.

  View details for DOI 10.1016/j.ijrobp.2020.06.047

  View details for PubMedID 32890524

• Patterns of Failure in Women Who Have Residual Nodal Disease After Neoadjuvant Chemotherapy for Breast Cancer According to Extent of Lymph Node Surgery. Clinical breast cancer Kozak, M. M., Horst, K. C., Gutkin, P. M., Jacobson, C. E., Walck, E., von Eyben, R., Dirbas, F. M. 2020

  Abstract

  BACKGROUND: Optimal surgical management of limited axillary nodal disease following neoadjuvant chemotherapy (NAC) for breast cancer is evolving. Concerns exist with respect to leaving residual disease in the axilla when omitting axillary lymph node dissection (ALND) in this setting. We sought to determine whether extent of nodal surgery altered patterns of failure and patient outcomes.PATIENTS AND METHODS: We identified 70 patients with breast cancer who were confirmed cN0 after NAC yet had residual nodal disease (ypN1) on sentinel lymph node biopsy (SLNB). Twenty-eight patients underwent SLNB alone and 42 underwent SLNB+completion (c)ALND in a non-randomized fashion. Most (n= 65) patients underwent adjuvant regional nodal irradiation (RNI). Detailed patterns of failure data were obtained for each patient.RESULTS: The median follow-up was 43.5 months. There were 30 (43%) recurrences. Of these, 5 were isolated locoregional failures, and 24 were distant failures. There were no significant differences in local (P= .13), regional (P= .62), or distant (P= .47) failure between patients who underwent SLNB alone versus SLNB+cALND. Seventeen (24%) patients died. Overall survival was similar in both groups with median overall survival not reached for those who underwent SLNB and 109 months for those who underwent SLNB+cALND (P= .45).CONCLUSIONS: There were no differences in patterns of recurrence among patients with 1 to 3 involved lymph nodes after NAC who underwent SLNB alone versus SLNB+cALND in the setting of RNI. We await the results of ongoing, prospective clinical trials to confirm the relative merits of RNI in lieu of cALND in these patients.

  View details for DOI 10.1016/j.clbc.2020.04.008

  View details for PubMedID 32522481

• Durability of response in metastatic melanoma patients after combined treatment with radiation therapy and ipilimumab. Melanoma management Sodji, Q. H., Gutkin, P. M., Swetter, S. M., Reddy, S. A., Hiniker, S. M., Knox, S. J. 2020; 7 (1): MMT36

  Abstract

  Aim: We previously reported a prospective trial evaluating the safety and efficacy of combining ipilimumab and radiation therapy in patients with metastatic melanoma. Herein, we provide a long-term update on patients with complete response (CR) or partial response (PR).Patients & methods: We continued to follow these patients with serial imaging including computed tomography, PET or MRI.Results: Two of the three patients with CR are still alive and without evidence of melanoma but with chronic treatment-induced hypophysitis. The third patient died of hepatocellular carcinoma, but with no evidence of melanoma. Among the three patients with PR, two achieved CR after pembrolizumab monotherapy.Conclusion: This long-term follow up reveals the striking durability of the CRs, which appears to correlate with a grade 2-3 hypophysitis.

  View details for DOI 10.2217/mmt-2019-0020

  View details for PubMedID 32399174

• Health mindset is associated with anxiety and depression in patients undergoing treatment for breast cancer. The breast journal Gutkin, P. M., Fero, K. E., Jacobson, C. E., Chen, J. J., Liang, R. V., Kolar, C., von Eyben, R., Horst, K. C. 2020

  View details for DOI 10.1111/tbj.13765

  View details for PubMedID 31999018

• Impact of Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) on Anesthesia Use, Payer Charges, and Treatment Time in Pediatric Patients. Practical radiation oncology Balazy, K. E., Gutkin, P. M., Skinner, L., von Eyben, R., Fowler, T., Pinkham, D. W., Rodriguez, S., Maxim, P. G., Donaldson, S. S., Loo, B. W., Bush, K., Hiniker, S. M. 2020

  Abstract

  PURPOSE: Pediatric radiotherapy requires optimal immobilization that often necessitates daily anesthesia. To decrease anesthesia use, we implemented a novel XXX system which projects video onto a radiolucent screen within the child's line of vision to provide attentional diversion. We investigated its reduction on anesthesia use, payer charges, and treatment time, as well as its impact on radiation delivery.METHODS AND MATERIALS: A 6-year retrospective analysis was performed among children undergoing radiotherapy (n=224), 3 years before and 3 after introduction of XXX. The frequency of anesthesia use before and after XXX implementation, as well as radiotherapy treatment times were compared. The number of spared anesthesia treatments allowed for a charge to payer analysis. To document lack of surface dose perturbation by XXX, a phantom craniospinal treatment course was delivered both with and without XXX. Additionally, an ion chamber course was delivered to document changes to dose at depth.RESULTS: More children were able to avoid anesthesia use entirely in the post-XXX cohort, compared to the pre-XXX cohort (73.2% vs 63.4%, p=0.03) and fewer required anesthesia for each treatment (18.8% vs 33%; p = 0.03). XXX introduction reduced anesthesia use for all ages studied. Treatment time per session was reduced by 38% using XXX compared to anesthesia. There were 326 fewer anesthesia sessions delivered over three years after XXX was introduced, with an estimated savings of > $500,000. OSLDs revealed a small increase in dose of 0.8%-9.5% with XXX, while the use of a thermomolded face mask increased skin dose as much as 58%.CONCLUSIONS: XXX introduction decreased anesthesia use in children undergoing radiotherapy; more avoided anesthesia entirely, and fewer needed it for every treatment. This resulted in a reduction in treatment time, and savings of nearly $550,000 in approximately 3 years, with minimal perturbation of radiotherapy dose delivery.

  View details for DOI 10.1016/j.prro.2019.12.009

  View details for PubMedID 31935524

• Erythema of the skin after breast radiotherapy: It is not always recurrence. International wound journal Gutkin, P. M., Fernandez-Pol, S. n., Horst, K. C. 2020

  Abstract

  Recurrence of breast cancer is a predominant fear for patients who were treated for breast cancer. Acute and late dermatologic effects of radiotherapy are not uncommon and could have similar characteristics to breast cancer recurrence. Thus, it is important to highlight key differences between the clinical and histologic presentations of radiation effects and recurrence. Herein, we present two patients who presented with late dermatologic effects of radiotherapy months to years after treatment, neither of whom had workup consistent with cancer recurrence. We provide clinical and microscopic descriptions of each case and provide a review to differentiate various dermatologic conditions. This report aims to outline potential late dermatologic effects of radiation treatment and emphasise that changes in the breast do not always signal breast cancer recurrence.

  View details for DOI 10.1111/iwj.13350

  View details for PubMedID 32227450

• Importance of a Culture Committee for Boosting Morale and Maintaining a Healthy Work Environment in Radiation Oncology. Advances in radiation oncology Gutkin, P. M., Minneci, M. O., Valenton, J. n., Kovalchuk, N. n., Chang, D. T., Horst, K. C. 2020

  Abstract

  During the unprecedented workplace disruption from the corona virus disease 2019 (COVID-19) pandemic, health care workers have been particularly vulnerable to increased work-related stress and anxiety. This may have a negative effect on job performance and personal well-being. Personal safety, job security, and childcare needs are essential concerns that must be addressed by health care organizations to ensure stability of its workforce. In addition, workplace morale is also damaged by the many daily changes brought about by social distancing. Thus, opportunities exist for departments to address the loss of social bonding and cohesiveness needed for successful team building. In this report, we describe the efforts of our departmental workplace culture committee during this pandemic.

  View details for DOI 10.1016/j.adro.2020.07.002

  View details for PubMedID 32838068

  View details for PubMedCentralID PMC7368646

• Successful Full-term Pregnancies After High-dose Pelvic Radiotherapy for Ewing Sarcoma: A Case Report. Journal of pediatric hematology/oncology Gutkin, P. M., Chen, E. L., Miller, C. J., Donaldson, S. S., Kovalchuk, N., Callejas, M. J., Hiniker, S. M. 2019

  Abstract

  Survivors of childhood cancer are at risk of long-term sequelae that arise as a consequence of cancer treatment. Radiation and chemotherapy treatment in pediatric female patients can have detrimental impacts on fertility, particularly in those with pelvic tumor involvement. We report 2 successful natural full-term pregnancies with vaginal delivery in a woman 12 years after biopsy, irradiation (55.5Gy), and multi-agent chemotherapy for treatment of pelvic Ewing sarcoma. Both children were born healthy, with no complications in pregnancy or delivery. Fertility preservation and risk assessment following chemotherapy/radiation therapy is evolving, providing new data to effectively counsel and treat young women.

  View details for DOI 10.1097/MPH.0000000000001581

  View details for PubMedID 31415018

• Treatment and outcomes in classic Hodgkin lymphoma post-transplant lymphoproliferative disorder in children PEDIATRIC BLOOD & CANCER Twist, C. J., Hiniker, S. M., Gratzinger, D., Gutkin, P. M., Merriott, D. J., Iagaru, A., Link, M. P., Donaldson, S. S. 2019; 66 (8)

  View details for DOI 10.1002/pbc.27803

  View details for Web of Science ID 000472549200013

• Volumetric Modulated Arc Therapy and 3-Dimensional Printed Bolus in the Treatment of Refractory Primary Cutaneous Gamma Delta Lymphoma of the Bilateral Legs PRACTICAL RADIATION ONCOLOGY Obeid, J., Gutkin, P. M., Lewis, J., Skinner, L., Wang, E. B., Khodadoust, M. S., Kim, Y. H., Weng, W., Hoppe, R. T., Hiniker, S. M. 2019; 9 (4): 220–25

  View details for DOI 10.1016/j.prro.2019.02.016

  View details for Web of Science ID 000472574100020

• Association between primary language, a lack of mammographic screening, and later stage breast cancer presentation CANCER Balazy, K. E., Benitez, C. M., Gutkin, P. M., Jacobson, C. E., von Eyben, R., Horst, K. C. 2019; 125 (12): 2057–65

  View details for DOI 10.1002/cncr.32027

  View details for Web of Science ID 000470925600016

• FLT-PET-CT for the Detection of Disease Recurrence After Stereotactic Ablative Radiotherapy or Hyperfractionation for Thoracic Malignancy: A Prospective Pilot Study FRONTIERS IN ONCOLOGY Hiniker, S. M., Sodji, Q., Quon, A., Gutkin, P. M., Arksey, N., Graves, E. E., Chin, F. T., Maxim, P. G., Diehn, M., Loo, B. W. 2019; 9

  View details for DOI 10.3389/fonc.2019.00467

  View details for Web of Science ID 000470114000001

• FLT-PET-CT for the Detection of Disease Recurrence After Stereotactic Ablative Radiotherapy or Hyperfractionation for Thoracic Malignancy: A Prospective Pilot Study. Frontiers in oncology Hiniker, S. M., Sodji, Q., Quon, A., Gutkin, P. M., Arksey, N., Graves, E. E., Chin, F. T., Maxim, P. G., Diehn, M., Loo, B. W. 2019; 9: 467

  Abstract

  Differentiating local recurrence from post-treatment changes on PET scans following stereotactic ablative radiotherapy (SABR) or hyperfractionation for lung tumors is challenging. We performed a prospective pilot study of 3-deoxy-3-[18F]-fluorothymidine (FLT)-PET-CT in patients with equivocal post-radiation FDG-PET-CT to assess disease recurrence. Methods: We prospectively enrolled 10 patients, 9 treated with SABR and 1 with hyperfractionated external beam radiotherapy for thoracic malignancy with subsequent equivocal follow-up FDG-PET-CT, to undergo FLT-PET-CT prior to biopsy or serial imaging. FLT-PET scans were interpreted by a radiologist with experience in reading FLT-PET-CT and blinded to the results of any subsequent biopsy or imaging. Results: Of the 10 patients enrolled, 8 were evaluable after FLT-PET-CT. Based on the FLT-PET-CT, a blinded radiologist accurately predicted disease recurrence vs. inflammatory changes in 7 patients (87.5%). The combination of higher lesion SUVmax and higher ratio of lesion SUVmax to SUVmax of mediastinal blood pool was indicative of recurrence. Qualitative assessment of increased degree of focality of the lesion also appears to be indicative of disease recurrence. Conclusion: Adjunctive FLT-PET-CT imaging can complement FDG-PET-CT scan in distinguishing post-treatment radiation changes from disease recurrence in thoracic malignancies. These findings support the investigation of FLT-PET-CT in a larger prospective study.

  View details for DOI 10.3389/fonc.2019.00467

  View details for PubMedID 31214507

  View details for PubMedCentralID PMC6555304

• Treatment and outcomes in classic Hodgkin lymphoma post-transplant lymphoproliferative disorder in children. Pediatric blood & cancer Twist, C. J., Hiniker, S. M., Gratzinger, D., Gutkin, P. M., Merriott, D. J., Iagaru, A., Link, M. P., Donaldson, S. S. 2019: e27803

  Abstract

  Classic Hodgkin lymphoma post-transplant lymphoproliferative disorder (HL-PTLD) has been rarely reported in children, with limited data available to guide treatment decisions. We report a retrospective review of five children diagnosed with classic HL-PTLD following solid organ transplant between 2007 and 2013 at Stanford University. Patients were treated with Stanford V chemotherapy and involved field radiation therapy. With a median follow-up of 7.2 years (range, 4.7-10.5 years) since diagnosis, all patients remain in remission from HL-PTLD and free from graft failure. In this series, combined modality therapy with risk-adapted chemotherapy and radiation therapy was a successful strategy for the treatment of classic HL-PTLD.

  View details for PubMedID 31062898

• Volumetric modulated arc therapy and 3-dimensional printed bolus in the treatment of refractory primary cutaneous gamma delta lymphoma of the bilateral legs. Practical radiation oncology Obeid, J., Gutkin, P. M., Lewis, J., Skinner, L., Wang, E. B., Khodadoust, M. S., Kim, Y. H., Weng, W., Hoppe, R. T., Hiniker, S. M. 2019

  Abstract

  Patients with extensive dermal and subcutaneous disease present a technical challenge for treatment with radiation therapy (RT). Volumetric arc therapy (VMAT) can effectively treat disease on circumferential surfaces while minimizing dose to the core structures. However, treatment of extensive areas of the bilateral lower extremities with this technique has not been previously reported. Here we report the successful treatment of a patient with primary cutaneous gamma-delta T-cell lymphoma of the bilateral legs using VMAT and a custom 3-dimensional printed bolus. This approach is applicable for the treatment of cutaneous malignancies of the lower extremities.

  View details for PubMedID 30836188

• Association between primary language, a lack of mammographic screening, and later stage breast cancer presentation. Cancer Balazy, K. E., Benitez, C. M., Gutkin, P. M., Jacobson, C. E., von Eyben, R., Horst, K. C. 2019

  Abstract

  BACKGROUND: Health determinants are known to influence the stage of breast cancer presentation, but it is unclear to what extent language affects stage. This study investigates whether non-English-speaking (NES) patients present at a later stage than their English-speaking (ES) counterparts and whether language is associated with mammographic screening.METHODS: This study was a retrospective, single-institution cohort analysis of women undergoing breast radiotherapy from 2012 to 2017 (n=1057). Patients were categorized as ES (n=904) or NES (n=153). Ordinal logistic regression analysis identified variables associated with later stage presentation, including language, race/ethnicity, and age. A subcohort analysis investigated the influence of mammographic screening on stage for NES patients.RESULTS: NES patients had greater odds of later stage disease than ES patients (odds ratio, 1.47; 95% confidence, 1.001-2.150). This association persisted across all races/ethnicities. An additional analysis examined age categories associated with mammographic screening. For women eligible for screening (ie, those 40-50years old or older than 50years), there was a significant association between language and stage. NES patients older than 50years were twice as likely to present at an advanced stage in comparison with ES patients (16.19% vs 8.11%; P=.0082). An additional subset analysis accounted for mammograms. NES patients who did not undergo screening had a higher probability of stage III disease (40.3% of NES patients vs 12.7% of ES patients). There was no difference in stage between NES and ES patients who did undergo screening.CONCLUSIONS: Language is independently associated with later stage breast cancer for NES patients, regardless of race/ethnicity. NES patients may have difficulty in accessing the health care system. Future interventions should seek to reduce language barriers for mammographic screening and diagnosis.

  View details for PubMedID 30768784

• Central Nervous System Relapse After Stem Cell Transplantation in Adolescents and Young Adults with Acute Lymphoblastic Leukemia: A Single-Institution Experience. Journal of adolescent and young adult oncology Kozak, M. M., Yoo, C. H., Gutkin, P. M., von Eyben, R. n., Agarwal, R. n., Donaldson, S. S., Muffly, L. n., Hiniker, S. M. 2019

  Abstract

  Purpose: To evaluate outcomes and central nervous system (CNS) relapse in adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL), who underwent total body irradiation (TBI) before allogeneic hematopoietic stem cell transplantation (allo-SCT). Methods: A total of 136 AYA patients with ALL who received TBI before allo-SCT between 1998 and 2018 were reviewed. Twenty patients received cranial radiation in their initial treatment before conditioning for transplant and were excluded. Competing risk analysis was used to estimate the cumulative incidence of relapse. Kaplan-Meier and log-rank tests were used to calculate overall survival (OS) and to identify factors predictive of relapse. OS and time to relapse were calculated from date of allo-SCT. Results: One hundred sixteen patients were included in the analysis. Median age was 27 years and median follow-up time was 42 months. Twenty-six patients suffered a disease relapse and 49 died, 26 of posttransplantation complications. The median time to relapse was 7 months and the 5-year OS was 60%. Seven patients had a CNS relapse: 4 of 20 patients (25%) with pre-SCT CNS disease had a post-allo-SCT CNS relapse compared to 3 of 97 (3.1%) without pre-SCT CNS disease. Median time to CNS relapse was 7 months. Patients with post-SCT CNS relapse had median OS of 19 months. Conclusions: AYA patients with CNS disease who undergo an allo-SCT have a high rate of CNS relapse. The addition of additional CNS-directed therapy to transplant protocols warrants further investigation.

  View details for DOI 10.1089/jayao.2019.0121

  View details for PubMedID 31747341

• Systemic Inflammation after Radiation Predicts Locoregional Recurrence, Progression, and Mortality in Stage II-III Triple-Negative Breast Cancer. International journal of radiation oncology, biology, physics Sherry, A. D., von Eyben, R. n., Newman, N. B., Gutkin, P. n., Mayer, I. n., Horst, K. n., Chakravarthy, A. B., Rafat, M. n. 2019

  Abstract

  Patients with triple-negative breast cancer experience high rates of recurrence following radiation, which may be facilitated by the recruitment of circulating tumor cells to pro-inflammatory microenvironments in the absence of lymphocytes. We hypothesized that patients with lymphopenia and elevated inflammatory hematologic markers after radiotherapy would have an increased risk of locoregional failure.With approval, we retrospectively studied a cohort of women treated with adjuvant radiotherapy for stage II-III triple-negative breast cancer. We analyzed the relationship between post-radiotherapy neutrophil:lymphocyte ratio (NLR) and locoregional recurrence by Cox regression.130 patients met inclusion criteria, and median follow up time was 7.6 years. Patients with an NLR ≥ 3 had a higher rate of locoregional failure (p=0.04) and lower overall survival (p=0.04). After adjusting for stage (HR = 5.5, p < 0.0001) and neoadjuvant chemotherapy (HR = 2.5, p = 0.0162), NLR was highly predictive of locoregional failure, (HR = 1.4, p = 0.0009). NLR was also highly predictive of overall survival (HR = 1.3, p = 0.0007) after adjustment for stage and neoadjuvant chemotherapy.Innate peripheral inflammation following radiotherapy for triple-negative breast cancer in an immunocompromised setting may be a novel prognostic biomarker for locoregional recurrence, progression, and survival. This finding supports preclinical studies of post-radiotherapy inflammation-mediated tumor progression. Further studies are needed to confirm this finding and develop treatment strategies.

  View details for DOI 10.1016/j.ijrobp.2019.11.398

  View details for PubMedID 31809877

• Outcomes for pediatric patients with osteosarcoma treated with palliative radiotherapy. Pediatric blood & cancer Chen, E. L., Yoo, C. H., Gutkin, P. M., Merriott, D. J., Avedian, R. S., Steffner, R. J., Spunt, S. L., Pribnow, A. K., Million, L. n., Donaldson, S. S., Hiniker, S. M. 2019: e27967

  Abstract

  Few studies have addressed the efficacy of palliative radiotherapy (RT) for pediatric osteosarcoma (OS), a disease generally considered to be radioresistant. We describe symptom relief, local control, and toxicity associated with palliative RT among children with OS.Patients diagnosed with OS at age 18 and under and treated with RT for palliation of symptomatic metastases or local recurrence at the primary site from 1997 to 2017 were included. We retrospectively reviewed details of RT, symptom improvement, local control, survival, and toxicity.Thirty-two courses of palliative RT were given to 20 patients with symptomatic metastatic and/or locally recurrent primary disease. The median equivalent dose in 2 Gy fractions (EQD2) was 40.0 Gy (range, 20.0-60.4). The median number of fractions per course was 15 (range, 5-39). Symptom improvement occurred in 24 (75%) courses of RT at a median time of 15.5 days (range, 3-43). In nine courses (37.5%), symptoms recurred after a median duration of symptom relief of 140 days (range, 1-882). Higher EQD2 correlated with longer duration of response (r = 0.39, P = 0.0003). Imaging revealed local failure in 3 of 14 courses followed with surveillance imaging studies (21.4%). The median time to progression was 12.9 months (range, 4.4-21.8). The median follow-up time following the first course of palliative RT was 17.5 months (range, 1.74-102.24), and median time to overall survival was 19.4 months. Toxicity was mild, with grade 2 toxicity occurring in one course (3.1%).RT is an effective method of symptom palliation for patients with recurrent or metastatic OS, with higher delivered dose correlating with longer symptom relief and with little associated toxicity.

  View details for DOI 10.1002/pbc.27967

  View details for PubMedID 31407520

• Complete Response of Metastatic Melanoma to Local Radiation and Immunotherapy: 6.5 Year Follow-Up. Cureus Gutkin, P. M., Hiniker, S. M., Swetter, S. M., Reddy, S. A., Knox, S. J. 2018; 10 (12): e3723

  Abstract

  The combined use of immunotherapy and radiation therapy is emerging as a potentially effective treatment for patients with immunogenic tumors such as melanoma; however, evidence for long-term treatment outcomes is lacking. Herein, we summarize our previously described case study of a patient with metastatic melanoma treated with two cycles of ipilimumab, followed by stereotactic body radiotherapy to two of seven liver metastases, with two additional cycles of ipilimumab. In the longest follow-up to date, we report a successful treatment outcome at 6.5 years. Our patient remains in complete remission, with no evidence of disease or recurrence 6.5 years after treatment. He continues to manage chronic hypophysitis developed secondary to immunotherapy and has developed osteopenia from prolonged systemic glucocorticoid use. The use of radiotherapy in combination with targeted immune therapy appears to be an effective treatment strategy, with long-lasting efficacy.

  View details for PubMedID 30788205

• Complete Response of Metastatic Melanoma to Local Radiation and Immunotherapy: 6.5 Year Follow-Up CUREUS Gutkin, P. M., Hiniker, S. M., Swetter, S. M., Reddy, S. A., Knox, S. J. 2018; 10 (12)

  View details for DOI 10.7759/cureus.3723

  View details for Web of Science ID 000461069500022