SBRT outcomes for primary and metastatic liver lesions

262

Background: Stereotactic body radiation therapy (SBRT) permits precise delivery of 1-5 high doses of radiation to liver tumors with low risk of toxicity. This study aims to evaluate local control and overall survival (OS) in patients treated with SBRT for primary and metastatic liver lesions.

Methods: From 2006 to 2010, 62 patients with 106 liver lesions (71 metastatic, 35 primary) were treated with SBRT. Lesions were most commonly from primary hepatocellular carcinoma (29%), or colorectal (23%), breast (8%), or esophageal metastases (8%). Patients were heavily pretreated: 51% received ≥1 prior form of liver-directed therapy and 54% received ≥1 prior systemic therapy regimen. The number of active hepatic lesions at the time of SBRT was 1 in 49%, 2 in 23%, 3 in 22%, and ≥4 in 7%. Of the metastatic lesions, 42% were accompanied by active extrahepatic disease. Of the primary liver lesions, 69% were Child-Pugh class A, 26% class B, and 6% class C. Median gross tumor volume (GTV) was 8.8 cm3 (range 0.2-222.4). Median biological equivalent prescription dose (BED10) was 100 Gy (42.6-180). The majority of patients received either 3 or 5 fractions (47% and 48%, respectively).

Results: Median follow-up for all lesions was 18 months (4.6-46.8). Local tumor control was observed in 92/106 treated lesions with 1- and 2-yr local control rates of 88% and 74%. No correlation was found between local control and lesion type (primary vs metastatic), lesion size, or prior liver directed therapy. Median survival for all patients was 25.2 months, with 1- and 2-year OS of 81% and 52%. Survival was longer among patients with metastatic lesions compared to primary lesions (2-yr OS 63% vs 29%, HR 0.46, p=0.02). The number of active hepatic lesions was an independent prognostic factor for survival (HR 1.77, p=0.002). For patients with metastatic liver lesions, the presence of active extrahepatic disease yielded significantly worse survival (2-yr OS 37% vs 83%). Among HCC patients, a lower CLIP score was associated with improved survival with 2-yr OS of 55% for CLIP score 0, 44% for score 1, 17% for score 2, and 0% for score 3. No patients experienced RILD.

Conclusions: Treatment of liver tumors with SBRT provides excellent local control, necessitating further improvements in systemic therapy.

No significant financial relationships to disclose.

Prospective assessment of symptoms and quality of life in localized rectal cancer patients receiving chemoradiotherapy

504

Background: Neoadjuvant conformal chemoradiotherapy (CRT) is an important component of treatment for locally advanced rectal cancer, yet its morbidity has not been well characterized using quality of life (QOL) instruments. The present study attempts to establish a baseline distribution of QOL scores before, during, and after CRT and to correlate these changes with symptoms.

Methods: Patients undergoing 3-4 field neoadjuvant CRT for localized rectal cancer were prospectively enrolled at two institutions. Fifty patients completed the QOL instruments at three time points: pretreatment, week 4 of treatment, and 1 month post-treatment. QOL information was captured using three validated questionnaires, the EORTC QLQ-30, QLQ-38, and QLQ-29. Additionally, institutional symptom inventories and CTCAE toxicity data were collected.

Results: Average age was 59.2 years and 72% were men. During CRT, patients had a statistically significant decline in global QOL (70 to 60, p = 0.0024), which normalized (71) following completion of treatment. During therapy, patients also experienced a significant increase in GI symptoms (21 to 27, p = 0.028), urinary symptoms (16 to 30, p < 0.0001), male sexual dysfunction (23 to 34, p = 0.013), and chemotherapy related side effects (8 to 20, p = 0.0001). While these measures returned to baseline 1 month post-CRT, overall sexual function (25 vs. 37, p = 0.0062) and sexual enjoyment (53 vs. 67, p = 0.0070) remained persistently low compared to pretreatment levels. Diarrhea (27%) and proctitis (22%) were the most common grade 3 toxicities. Those patients who experienced grade 3 toxicity during treatment showed markedly decreased global QOL (mean difference = 34).

Conclusions: While rectal cancer patients experienced impaired QOL during neoadjuvant CRT, the vast majority of measures normalized one month after treatment. In contrast, significantly decreased sexual function and enjoyment persisted. This data can be used as a baseline to compare future neoadjuvant conformal CRT regimens and/or assess the toxicity and QOL of new RT modalities such as intensity modulated radiation therapy.

No significant financial relationships to disclose.

Phase II trial of neoadjuvant full-dose gemcitabine, oxaliplatin, and radiation (RT) in patients with resectable (R) or borderline resectable (BR) pancreatic cancer

239

Background: We previously developed a regimen of full dose gemcitabine (gem), oxaliplatin (ox) and RT to maximize systemic and loco-regional disease control in pancreas cancer (JCO 25:4587, 2007). A multi-institution phase II trial was conducted to test efficacy of this regimen as neoadjuvant therapy in R/BR disease.

Methods: Eligibility criteria included path confirmation, no metastasis, R/BR lesion, PS ≤2, and adequate organ function. Treatment consisted of 2, 28 day cycles of gem (1g/m2 over 30 min D1, 8, 15) and ox (85mg/m2 D1, 15) with RT during cycle 1 (30Gy in 2Gy fractions). Pts were then re-evaluated for surgery. Resected pts received 2 additional cycles of chemotherapy.

Results: 68 evaluable pts were treated at 4 centers in 2007-2010. Median age was 64 (42-83), 32 men, PS 0:1:2 in 40:26:2. Median tumor size 3.2 cm (1.4–7.8), lesion in head 49, body 9, tail 10, R in 24 and BR in 44. 66 pts (97%) completed cycle 1/RT and 61 (90%) cycle 2. Therapy related adverse events ≥ grade 3 in cycles1/2 included ANC (32%), plts (24%), GI (16%), biliary/cholangitis (15%). Best response in primary was partial (10%) or stable (81%). 20 pts not operated on protocol: 8 progression (4 local, 4 distant), 8 judged not resectable, 3 toxicity, 1 early death. Of 48 laparotomies,10 not resected due to vascular involvement (6) or M1 disease (4). Resection completed in 15 of 18 R pts (13 R0, 2 R1) and 23 of 30 BR pts (19 R0, 2 R1, 2 R2). 26 pts received post-op therapy. With median fu 11.3 mos (0.7-35), 42 pts are alive, 20 pts are NED. Median survival (OS) for all pts is 21.2 mos (95%CI 13.3-not defined [ND]), resected 31.1 mos (95%CI 13.7-ND), unresected 16.0 mos (95%CI 5.8-ND). Time to treatment failure (death, progression, toxicity, no resection) and OS in R pts are 9.1 mos (95%CI 2.4-23.8) and 31.1 mos (95%CI 9.8-ND) and in BR pts 5.5 mos (95%CI 2.4-11.8) and 18.0 mos (95%CI 13.3-ND). Correlation of pathologic response and outcome is ongoing.

Conclusions: Neoadjuvant therapy with full dose gem, ox and RT was possible in a large proportion of pts with localized pancreas cancer and resulted in a high percentage of R0 resections. Results are particularly encouraging given a majority of pts with BR disease.

[Table: see text]

Multicenter evaluation of adjuvant therapy for gallbladder cancer

251

Background: To assess the effect of adjuvant therapy in gallbladder adenocarcinoma (GBC).

Methods: Retrospective review was conducted at five institutions to identify pts who had surgery for confirmed dx of GBC from 1985-2008 (N = 189). Pts were excluded if they had chemo alone (N = 8), path other than adenoca (N= 7), carcinoma in situ (N=1), < 30 days of follow-up (N = 2), or missing data (N=14). Of the remaining 156 pts, 58 received surgery only and 98 received adj RT ± chemo. Kaplan-Meier was used for overall survival (OS) and Cox proportional hazards to compare risk factors.

Results: Median age of dx was 64.4, 68.0% were female, 37.9% had ≥ stage 2b, 37.2% had + nodes, and 32.1% had + margins. Overall, 35.9% of the patients had simple cholecystectomy (SC) only and 64.1% had radical resection (ER). mOS for pts treated with surgery alone was 49.7 months (95% CI: 24.8 to Inf). On univariate analysis, + margins (HR 2.72, p<0.001) was associated with worse OS, whereas ER compared to SC improved survival in both univariate (HR 0.46, p<0.001) and multivariate (HR 0.53, p=0.033) analyses after adjusting for node/margins, T-stage, adj RT, age, gender, and institution. mOS for the entire cohort vs. adj RT (median 50.4 Gy) ± chemo was 30.7 months (95% CI: 19.2 to 46.9) vs. 26.9 months (95% CI: 15.5 to 39.1). But, compared to surgery alone, the adj group was more likely to have had node +, margin +, or T-stage 3+ (all p<0.001). The adj RT group was also less likely than surgery alone pts to have undergone ER (p = 0.007). On multivariate analysis, decreased OS was also found for node + (HR 2.09, p=0.004), margin + (HR 1.84, p=0.043), and T3/T4 disease (HR 2.37, p=0.002). After adjusting for surgical extent, node, margin, T stage, age, gender, and institution, there was improved OS with adj therapy (HR: 0.43, p = 0.020). When stratified by surgical extent, the risk estimate for adj RT improved OS among those with SC (n=56; HR 0.20, p=0.135) and ER (n=100; HR 0.46, p=0.067), but was not statistically significant.

Conclusions: ER was associated with improved OS, whereas node/margin+ and T-stage 3+ were associated with worse survival. In multivariate analysis, adj RT improved OS after surgery. Given the poor prognosis of GBC patients with advanced disease, consideration of adj therapy is appropriate.

No significant financial relationships to disclose.

Phase I radiation dose-escalation trial of intensity-modulated radiotherapy (IMRT) with concurrent fixed dose-rate gemcitabine (FDR-G) for unresectable pancreatic cancer

4602

Background: Current treatments of non-metastatic, unresectable pancreatic cancer result in poor survival and nearly uniform local persistence of disease. We hypothesized that intensification of local therapy would result in better local control and improve survival. The primary objective of this trial was to determine maximum tolerated radiation dose delivered with IMRT and concurrent FDR-G. Methods: Eligibility included tissue diagnosis of adenocarcinoma, unresectable by radiological criteria, Zubrod performance of 0–2, ANC of ≥ 1500/mm3, platelets ≥ 100,000/mm3, creatinine < 2 mg/dl, bilirubin < 3 mg/dl, ALT and AST ≤ 2.5 x ULN, and informed consent. Patients (pts) received FDR-G (1000 mg/m2, 100-minute infusion) on days -22 and -15. IMRT started day 1 (radiation dose levels [L2-L6] 50, 52.5, 55, 57.5 and 60 Gy, all in 25 fractions) with concurrent FDR-G on days 1, 8, 22, and 29. GTV was defined on pancreas protocol CT in the treatment position. PTV was GTV plus 1 cm expansion. Active Breathing Control was used to reduce breathing motion, except in 3 pts, in whom 4D CT was used to generate an ITV. Post IMRT, up to 4 cycles of FDR-G were given. DLT was defined as GI toxicity ≥ G3, neutropenic fever, or deterioration in Zubrod to ≥3 between day 1 and 126. IMRT dose level was assigned using the Time-to-Event Continual Reassessment Method. With a sample size of 50, the design allows concurrent assessment of efficacy. Results: From 8/06, 27 pts have been accrued. DLTs have been observed in 6 (G3 anorexia, nausea vomiting, and/or dehydration [5 pts]; duodenal bleed [1 pt]). The posterior estimates of probability of DLT are 0.17, 0.21, 0.24, 0.27, and 0.28 for L2 to L6, respectively. The response rate is 52.4% (95% CI 29.8% to 74.3%). The median overall survival and progression-free survival are 23.1 months (95% CI 9–23.1) and 7.2 months (95% CI 5.0–8.0), respectively. Only 1 patient (4%) progressed locally. Two patients have undergone resection (R0), and demonstrated near- and complete pathological responses. Conclusions: High dose radiotherapy and concurrent FDR-G, utilizing the techniques above, is well tolerated and results in highly encouraging response rates, local control rates and overall survival.

No significant financial relationships to disclose.

Prevalence of depression, sleep-related disturbances, and anxiety and their effect on quality of life in patients with adenocarcinoma of the pancreas

e15678

Purpose: To evaluate the prevalence of depression, sleep related disturbances and anxiety and their effect on quality of life in patients with recently diagnosed adenocarcinoma of the pancreas who present to a multidisciplinary pancreatic cancer clinic. Methods: Cross-sectional and longitudinal psychosocial distress was assessed utilizing Personal Health Questionnaire 9 (PHQ9) to screen for depression and monitor symptoms during the course of care, the Penn State Worry Questionnaire (PSWQ) for generalized anxiety, and the Sleep Problems Questionnaire 4 (SPQ4)/ University of Michigan Sleep Questionnaire to monitor sleep symptoms. Patients were evaluated at their intake consultation and at subsequent follow up visits. Results: 24 patients (pts; mean age 66 years, 48% females) consented to participate during the 6 month pilot study with longitudinal follow up for 13. The PHQ9 scores on presentation revealed mild to moderate depressive symptoms in 54% (13 pts) of pts and moderately severe depressive symptoms in only 8% (2 pts). A minority (2 pts, 8%) had PSWQ scores characteristic of an anxiety disorder, while 33% (8 pts) had moderate anxiety scores. Only 3 pts (12.5%) scores revealed a clear sleep problem; 10 pts, (41.67%) had no sleep problem and 10 pts had a potential sleep problem. Due to the limited follow up, a statistical difference in scores over time was not observed. Conclusions: Our results indicate that mild to moderate depressive symptoms, anxiety and potential sleep problems are common in patients referred to a multidisciplinary pancreatic cancer clinic. Moderately severe depressive symptoms, severe anxiety and clear sleep problems are not as prevalent as is generally believed. To better characterize the relationship of depression (and potential causes) with pancreatic cancer, additional prospective longitudinal studies are needed.

No significant financial relationships to disclose.

A phase I study of oxaliplatin, full-dose gemcitabine and concurrent radiation therapy in patients with pancreatic cancer

4107

Background: We previously demonstrated safety and efficacy of full dose gemcitabine (GEM) and radiation therapy (RT) in patients (pts) with pancreatic cancer (PC). Our preclinical studies have shown that GEM with oxaliplatin (OX) preserves radiosensitization with synergistic cytotoxicity. To enhance local and systemic treatment effects, we initiated a study of OX and GEM with concurrent RT. Methods: Pts with untreated PC received up to 4 cycles of GEM day 1, 8, 15 and OX days 1, 15 repeated at 28 day intervals. RT (27 Gy in 1.8 Gy fractions to gross tumor volume with 1 cm margin) was given during cycle 1 and repeated in cycle 4. Surgery occurred after cycle 2 in resectable pts. Dose escalation was guided using time-to-event continuous reassessment method (TITE-CRM). Dose levels 1–4 GEM 1 g/m2 IV over 30 min and OX 40, 55, 70, 85 mg/m2 IV over 90 min; dose level 5, 6 OX dose remained 85 mg/m2 but infusion time for GEM 1 g/m2 was increased to 65, 100 min, respectively. Trial objective is to determine dose level associated with DLT thru cycle 2 in ≤ 20% of pts; planned accrual is 40 pts evaluable for DLT. Results: 40 pts have been enrolled (median age 63, men/women 26/14) with resectable (10), unresectable (27), and metastatic (3) PC. 29 pts have completed 2 cycles and 11 pts 4 cycles. After 2 cycles CA19–9 decreased > 50% in 14 of 24 evaluable pts (58%). Six of 8 explored pts underwent margin negative resection with 1 path CR and 2 with small residual microscopic foci only. Per RECIST, CT response of the primary lesion after 2 cycles included 3 PR, 23 SD and 1 PD. Two additional PR were seen after cycle 4. Thirty pts are presently evaluable for DLT; 7 pts have suffered DLT including grade 4 platelets (4), decline in PS (2), GI bleed (1) and grade 3 weight loss (1). Current estimated probability of DLT is 21% (95% CI 11%,34%) for dose level 3 and 24% (95% CI 13%,37%) for dose level 4. Conclusions: The addition of OX 70–85 mg/m2 days 1, 15 to full dose GEM based RT is tolerable and efficacious. A neoadjuvant phase II study in resectable PC using the MTD defined in this phase I study is planned. Supported by Sanofi-Aventis.

[Table: see text]