Prognostic Factors for Pediatric, Adolescent, and Young Adult Patients with Non-DIPG Grade 4 Gliomas: A Contemporary Pooled Institutional Experience

PURPOSE/OBJECTIVE(S)

WHO grade 4 gliomas are rare tumors in the pediatric and AYA (adolescent and young adult) population. In this study, we evaluate prognostic factors, toxicities, and outcomes in the pediatric versus AYA population.

MATERIALS/METHODS

This retrospective pooled institutional study included patients < 30 years old with grade 4 gliomas. Overall survival (OS) and progression free survival (PFS) were characterized using Kaplan-Meier and Cox regression analysis.

RESULTS

Ninety-seven patients (n = 20 < 15y, n = 77 ≥ 15y) were identified with a median age 23.9y at diagnosis. Most had biopsy-proven glioblastoma (91%) and the remainder had diffuse midline glioma, H3K27M-altered (9%). All patients received surgery and adjuvant radiotherapy. Median PFS and OS were 20.9 months and 79.4 months, respectively. Gross total resection was associated with better PFS in multivariate analysis [HR 2.00 (1.01-3.62), p = 0.023]. Age ≥15y was also associated with improved OS [HR 0.36 (0.16-0.81), p = 0.014] while female gender [HR 2.12 (1.08-4.16), p = 0.03] and K27M altered histology [HR 2.79 (1.11-7.02), p = 0.029] were associated with worse OS. Only 7% of patients experienced grade 2 toxicity during radiation. Sixty-two percent of patients experienced tumor progression, 28% local and 34% distant. Analysis of salvage treatment found reirradiation was not associated with improved OS, but second surgery and systemic therapy significantly improved survival from the time of tumor progression.

CONCLUSION

Age is a significant prognostic factor in WHO grade 4 glioma, which may reflect age-related molecular alterations in the tumor. Diffuse midline glioma was associated with worse OS compared to hemispheric glioblastoma; this may be related to lack of effective targeted therapies. Surgery and systemic therapy were effective salvage options that significantly improved outcome. Better understanding of prognostic factors may guide future treatment within this understudied patient population, and prospective studies are warranted.

Prognostic factors for pediatric, adolescent, and young adult patients with non-DIPG grade 4 gliomas: a contemporary pooled institutional experience

PURPOSE

WHO grade 4 gliomas are rare in the pediatric and adolescent and young adult (AYA) population. We evaluated prognostic factors and outcomes in the pediatric versus AYA population.

METHODS

This retrospective pooled study included patients less than 30 years old (yo) with grade 4 gliomas treated with modern surgery and radiotherapy. Overall survival (OS) and progression-free survival (PFS) were characterized using Kaplan-Meier and Cox regression analysis.

RESULTS

Ninety-seven patients met criteria with median age 23.9 yo at diagnosis. Seventy-seven patients were ≥ 15 yo (79%) and 20 patients were < 15 yo (21%). Most had biopsy-proven glioblastoma (91%); the remainder had H3 K27M-altered diffuse midline glioma (DMG; 9%). All patients received surgery and radiotherapy. Median PFS and OS were 20.9 months and 79.4 months, respectively. Gross total resection (GTR) was associated with better PFS in multivariate analysis [HR 2.00 (1.01-3.62), p = 0.023]. Age ≥ 15 yo was associated with improved OS [HR 0.36 (0.16-0.81), p = 0.014] while female gender [HR 2.12 (1.08-4.16), p = 0.03] and DMG histology [HR 2.79 (1.11-7.02), p = 0.029] were associated with worse OS. Only 7% of patients experienced grade 2 toxicity. 62% of patients experienced tumor progression (28% local, 34% distant). Analysis of salvage treatment found that second surgery and systemic therapy significantly improved survival.

CONCLUSION

Age is a significant prognostic factor in WHO grade 4 glioma, which may reflect age-related molecular alterations in the tumor. DMG was associated with worse OS than glioblastoma. Reoperation and systemic therapy significantly increased survival after disease progression. Prospective studies in this population are warranted.

Postoperative Radiotherapy for Locally Advanced NSCLC: Implications for Shifting to Conformal, High-Risk Fields

BACKGROUND

To examine the effect of radiotherapy field size on survival outcomes and patterns of recurrence in patients treated with postoperative radiotherapy (PORT) for non-small-cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed the records of 216 patients with T1-4 N1-2 NSCLC following surgery and PORT using whole mediastinum (WM) or high-risk (HR) nodal fields from 1998 to 2015. Survival rates were calculated using the Kaplan-Meier method. Univariate and multivariable analyses were conducted using Cox proportional hazards modeling for outcomes and logistic regression analysis for treatment toxicities.

RESULTS

Median follow-up was 28 months (interquartile range [IQR] 13-75 months) and 38 months (IQR 19-73 months) for WM (n = 131) and HR (n = 84) groups, respectively. Overall survival (OS) was not significantly different between groups (median OS: HR 49 vs. WM 32 months; P = .08). There was no difference in progression-free survival (PFS), freedom from locoregional recurrence (LRR), or freedom from distant metastasis (P > .2 for all). Field size was not associated with OS, PFS, or LRR (P > .40 for all). LRR rates were 20% for HR and 26% for WM groups (P = .30). There was no significant difference in patterns of initial site of LRR between groups (P > .1). WM fields (OR 3.73, P = .001) and concurrent chemotherapy (odds ratio 3.62, P = .001) were associated with grade ≥2 toxicity.

CONCLUSIONS

Locoregional control and survival rates were similar between PORT groups; an improved toxicity profile was observed in the HR group. Results from an ongoing prospective randomized clinical trial will provide further insight into the consequences of HR PORT fields.

Real-world evaluation of the impact of radiotherapy and chemotherapy in elderly patients with glioblastoma based on age and performance status

Background

This retrospective study investigated the impact of, in addition to age, the management and outcomes of elderly patients with glioblastoma (GBM).

Methods

The National Cancer Database was queried between 2004 and 2015 for GBM patients age 60 years and older. Three age groups were created: 60 to 69, 70 to 79, and 80 years and older, and 4 age/KPS groups: "age ≥ 60/ KPS < 70" (group 1), "age 60 to 69/KPS ≥ 70" (group 2), "age 70 to 79/KPS ≥ 70" (group 3), and "age ≥ 80/KPS ≥ 70" (group 4). Multivariable (MVA) modeling with Cox regression determined predictors of survival (OS), and estimated average treatment effects analysis was performed.

Results

A total of 48 540 patients with a median age of 70 years (range, 60-90 years) at diagnosis, and a median follow-up of 6.8 months (range, 0-151 months) were included. Median survival was 5.0, 15.2, 9.6, and 6.8 months in groups 1, 2, 3, and 4, respectively (P < .001). On treatment effects analysis, all groups survived longer with combined chemotherapy (ChT) and radiation therapy (RT), except group 1, which survived longer with ChT alone (P < .001). RT alone was associated with the worst OS in all groups (P < .01). Across all groups, predictors of worse OS on MVA were older age, lower KPS, White, higher comorbidity score, worse socioeconomic status, community treatment, tumor multifocality, subtotal resection, and no adjuvant treatment (all P < .01).

Conclusions

In elderly patients with newly diagnosed GBM, those with good KPS fared best with combined ChT and RT across all age groups. Performance status is a key prognostic factor that should be considered for management decisions in these patients.

Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care

BACKGROUND

Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals.

MATERIALS AND METHODS

All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed.

RESULTS

In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045).

CONCLUSIONS

Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.

Single Institution Experience of Proton and Photon-based Postoperative Radiation Therapy for Non-small-cell Lung Cancer

INTRODUCTION

Postoperative radiation therapy (PORT) for non-small-cell lung cancer remains controversial with studies showing no overall survival (OS) benefit in the setting of excessive cardiopulmonary toxicity. Proton beam therapy (PBT) can potentially reduce toxicity with improved organ-at-risk sparing. We evaluated outcomes of PORT patients treated with PBT and intensity-modulated radiation therapy (IMRT).

MATERIALS AND METHODS

This is a retrospective review of 136 PORT patients (61 PBT, 75 IMRT) treated from 2003 to 2016. A Kaplan-Meier analysis was performed to assess oncologic outcomes. A Cox regression was conducted to identify associated factors. Total toxicity burden (TTB) was defined as grade ≥ 2 pneumonitis, cardiac, or esophageal toxicity.

RESULTS

Median OS was 76 and 46 months for PBT and IMRT with corresponding 1- and 5-year OS of 85.3%, 50.9% and 89.3%, 37.2% (P = .38), respectively. V30 Gy heart (odds ratio [OR], 144.9; 95% confidence interval [CI], 2.91-7214; P = .013) and V5 Gy lung (OR, 15.8; 95% CI, 1.22-202.7; P = .03) were predictive of OS. Organ-at-risk sparing was improved with PBT versus IMRT; mean heart 2.0 versus 7.4 Gy (P < .01), V30 Gy heart 2.6% versus 10.7% (P < .01), mean lung 7.9 versus 10.4 Gy (P = .042), V5 Gy lung 23.4% versus 42.1% (P < .01), and V10 Gy lung 20.4% versus 29.6% (P < .01). TTB was reduced with PBT (OR, 0.35; 95% CI, 0.15-0.83; P = .017). Rates of cardiac toxicity were 14.7% IMRT and 4.9% PBT (P = .09). Rates of ≥ grade 2 pneumonitis were 17.0% IMRT and 4.9% PBT (P = .104).

CONCLUSION

PBT improved cardiac and lung sparing and reduced toxicity compared with IMRT. Considering the impact of cardiopulmonary toxicity on PORT outcomes, PBT warrants prospective evaluation.

Proton Accelerated Partial Breast Irradiation: Clinical Outcomes at a Planned Interim Analysis of a Prospective Phase 2 Trial

PURPOSE

To perform a planned interim analysis of acute (within 12 months) and late (after 12 months) toxicities and cosmetic outcomes after proton accelerated partial breast irradiation (APBI).

METHODS AND MATERIALS

A total of 100 patients with pTis or pT1-2 N0 (≤3cm) breast cancer status after segmental mastectomy were enrolled in a single-arm phase 2 study from 2010 to 2019. The clinically determined postlumpectomy target volume, including tumor bed surgical clips and operative-cavity soft-tissue changes seen on imaging plus a radial clinical expansion, was irradiated with passively scattered proton APBI (34 Gy in 10 fractions delivered twice daily with a minimum 6-hour interfraction interval). Patients were evaluated at protocol-specific time intervals for recurrence, physician reports of cosmetic outcomes and toxicities, and patient reports of cosmetic outcomes and satisfaction with the treatment or experience.

RESULTS

Median follow-up was 24 months (interquartile range [IQR], 12-43 months). Local control and overall survival were 100% at 12 and 24 months. There were no acute or late toxicities of grade 3 or higher; no patients experienced fat necrosis, fibrosis, infection, or breast shrinkage. Excellent or good cosmesis at 12 months was reported by 91% of patients and 94% of physicians; at the most recent follow-up, these were 94% and 87%, respectively. The most commonly reported late cosmetic effect was telangiectasis (17%). The total patient satisfaction rate for treatment and results at 12 and 24 months was 96% and 100%, respectively. Patients' mean time away from work was 5 days (IQR, 2-5 days), and the median out-of-pocket cost was $700 (IQR, $100-$1600). The mean left-sided heart dose was 2 cGy (range, 0.2-75 cGy), and the mean ipsilateral lung dose was 19 cGy (range, 0.2-164 cGy).

CONCLUSIONS

Proton APBI is a maturing treatment option with high local control, favorable intermediate-term cosmesis, high treatment satisfaction, low treatment burden, and exceptional heart and lung sparing.

Outcomes and toxicities following stereotactic ablative radiotherapy for pulmonary metastases in patients with primary head and neck cancer

BACKGROUND

Metastatic head and neck cancers (HNCs) predominantly affect the lungs and have a two-year overall survival (OS) of 15% to 50%, if amenable for pulmonary metastasectomy.

METHODS

Retrospective review of the two-year local control (LC), local-regional control (LRC) within the same lobe, OS, and toxicity rates in consecutive patients with metastatic pulmonary HNC who underwent stereotactic ablative radiotherapy (SABR) January 2007 to May 2018.

RESULTS

Evaluated 82 patients with 107 lung lesions, most commonly squamous cell carcinoma (SCC; 64%). Median follow-up was 20 months (range: 9.0-97.6). Systemic therapy administered in 34%. LC, LRC, and OS rates were 94%, 90%, and 62%. Patients with oligometastatic disease had a higher OS than polymetastatic disease, 72% vs 44% (HR = 0.30, 95% CI: 0.14-0.64; P = .008). OS in oligometastatic non-SCC and SCC were 100% and 66% (P = .03). There were no grade ≥3 toxicities.

CONCLUSIONS

Metastatic pulmonary HNCs after SABR have a two-year OS rate comparable to pulmonary metastasectomy.

Spine stereotactic radiosurgery for metastatic thyroid cancer: a single-institution experience

OBJECTIVE

Patients with metastatic thyroid cancer have prolonged survival compared to those with other primary tumors. The spine is the most common site of osseous involvement in cases of metastatic thyroid cancer. As a result, obtaining durable local control (LC) in the spine is crucial. This study aimed to evaluate the efficacy of spine stereotactic radiosurgery (SSRS) in patients with metastatic thyroid cancer.

METHODS

Information on patients with metastatic thyroid cancer treated with SSRS for spinal metastases was retrospectively evaluated. SSRS was delivered with a simultaneous integrated boost technique using single- or multiple-fraction treatments. LC, defined as stable or reduced disease volume, was evaluated by examining posttreatment MRI, CT, and PET studies.

RESULTS

A total of 133 lesions were treated in 67 patients. The median follow-up duration was 31 months. Dose regimens for SSRS included 18 Gy in 1 fraction, 27 Gy in 3 fractions, and 30 Gy in 5 fractions. The histology distribution was 36% follicular, 33% papillary, 15% medullary, 13% Hurthle cell, and 3% anaplastic. The 1-, 2-, and 5-year LC rates were 96%, 89%, and 82%, respectively. The median overall survival (OS) was 43 months, with 1-, 2-, and 5-year survival rates of 86%, 74%, and 44%, respectively. There was no correlation between the absolute biological equivalent dose (BED) and OS or LC. Patients with effective LC had a trend toward improved OS when compared to patients who had local failure: 68 versus 28 months (p = 0.07). In terms of toxicity, 5 vertebral compression fractures (2.8%) occurred, and only 1 case (0.6%) of greater than or equal to grade 3 toxicity (esophageal stenosis) was reported.

CONCLUSIONS

SSRS is a safe and effective treatment option with excellent LC and minimal toxicity for patients with metastatic thyroid cancer. No association with increased radiation dose or BED was found, suggesting that such patients can be effectively treated with reduced dose regimens.

Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends

BACKGROUND

The purpose of this study was to assess treatment choices among men with prostate cancer who presented at The University of Texas MD Anderson Cancer Center multidisciplinary (MultiD) clinic compared with nationwide trends.

METHODS

In total, 4451 men with prostate cancer who presented at the MultiD clinic from 2004 to 2016 were analyzed. To assess nationwide trends, the authors analyzed 392,710 men with prostate cancer who were diagnosed between 2004 and 2015 from the Surveillance, Epidemiology, and End Results (SEER) database. The primary endpoint was treatment choice as a function of pretreatment demographics.

RESULTS

Univariate analyses revealed similar treatment trends in the MultiD and SEER cohorts. The use of procedural forms of definitive therapy decreased with age, including brachytherapy and prostatectomy (all P < .05). Later year of diagnosis/clinic visit was associated with decreased use of definitive treatments, whereas higher risk grouping was associated with increased use (all P < .001). Patients with low-risk disease treated at the MultiD clinic were more likely to receive nondefinitive therapy than patients in SEER, whereas the opposite trend was observed for patients with high-risk disease, with a substantial portion of high-risk patients in SEER not receiving definitive therapy. In the MultiD clinic, African American men with intermediate-risk and high-risk disease were more likely to receive definitive therapy than white men, but for SEER the opposite was true.

CONCLUSIONS

Presentation at a MultiD clinic facilitates the appropriate disposition of patients with low-risk disease to nondefinitive strategies of patients with high-risk disease to definitive treatment, and it may obviate the influence of race.

Volumetric assessment of apparent diffusion coefficient predicts outcome following chemoradiation for cervical cancer

OBJECTIVE

To determine the utility of volumetric diffusion weighted imaging (DWI) compared to other clinical factors for predicting recurrence and survival in cervical cancer patients treated with definitive chemoradiation.

METHODS AND MATERIALS

We retrospectively studied cervical cancer patients treated with definitive chemoradiation between 2009-2013 at a single institution with a baseline MRI with DWI and 18F-FDG positron emission tomography/computed tomography (FDG-PET) scan. To identify clinical and imaging metrics correlated with survival and recurrence endpoints, variable importance values were calculated from random forest models. To provide clinically relevant threshold values, recursive partitioning analysis dichotomized patients into potential risk groups based on selected metrics. Cox's proportional hazard models assessed the effect of clinical and imaging factors on survival endpoints.

RESULTS

Ninety-three patients were included in the analysis (median age 50 years). At a median follow-up of 35.6 months, 32 patients (34%) had disease recurrence. In the best multivariate model including clinical and imaging parameters, 90th percentile ADC < 1.917 was the only significantly associated factor with worse progression free survival (PFS). Overall survival, PFS, and distant metastasis free survival (DMFS) were significantly different between patient groups divided on 90th percentile ADC with threshold of 1.917 × 10^-3 mm²/s and MRI volume with threshold of 18.9 cc (P = 0.037, P = 0.0002, P = 0.001). High MRI volume and low ADC were associated with worse clinical outcomes.

CONCLUSIONS

Volumetric 90th percentile ADC value of the primary tumor on pretreatment MRI was a significant predictor of PFS and DMFS in cervical cancer patients, independent of established clinical factors and SUV on FDG-PET.

Clinical outcomes after intensity-modulated proton therapy with concurrent chemotherapy for inoperable non-small cell lung cancer

BACKGROUND & PURPOSE

We report disease control, survival, and toxicity in patients with advanced inoperable non-small cell lung cancer (NSCLC) receiving concurrent chemotherapy and intensity-modulated proton therapy (IMPT) at a single institution.

MATERIAL AND METHODS

All patients were treated with IMPT with concurrent chemotherapy. Endpoints assessed were local, regional, and distant control, disease-free survival (DFS), and overall survival (OS).

RESULTS

Fifty-one patients were enrolled with a median follow-up time of 23.0 months; 39 (76%) were treated with a simultaneous integrated boost to the gross tumor volume (GTV). The median GTV dose was 67.3 CGE and the median CTV dose was 60.0 CGE. Median OS and DFS times were 33.9 months and 12.6 months. The 3-year local control rate was 78.3%. Treatment was well tolerated, with a grade 3 toxicity rate of 18% (9 events: 4 esophagitis, 3 dermatitis, 1 esophageal stricture, and 1 fatigue) and no grade 4 or 5 toxicity. The most common grade 2 toxic effects were esophagitis (22 [43%]), dermatitis (16 [31%]), pain (15 [29%]), and fatigue (14 [27%]).

CONCLUSIONS

Treatment of inoperable NSCLC with IMPT and concurrent chemotherapy achieves excellent disease control with tolerable toxicity.

Dose Escalation for Prostate Adenocarcinoma: A Long-Term Update on the Outcomes of a Phase 3, Single Institution Randomized Clinical Trial

PURPOSE

To determine the long-term outcomes for prostate adenocarcinoma when escalating radiation dose from 70 Gy to 78 Gy.

METHODS AND MATERIALS

Between 1993 and 1998, 301 patients with biopsy-proven clinical stage T1b-T3 prostate adenocarcinoma, any prostate-specific antigen level, and any Gleason score were randomized to 70 Gy in 35 fractions versus 78 Gy in 39 fractions of photon radiation therapy using a 4-field box technique without hormone deprivation therapy. The primary outcome was powered to detect a 15% difference in biochemical or clinical failure. Secondary outcomes included survival, prostate cancer mortality, biochemical failure, local failure, nodal failure, distant failure, and secondary malignancy rates.

RESULTS

With a median follow-up of 14.3 years, the cumulative incidence of 15-year biochemical or clinical failure was 18.9% versus 12.0% in the 70 Gy versus 78 Gy arms, respectively (subhazard ratio [sHR], 0.61; 95% confidence interval [CI], 0.38-0.98; Fine-Gray P = .042). The 15-year cumulative incidence of distant metastasis was 3.4% versus 1.1%, respectively (sHR, 0.33; 95% CI, 0.13-0.82; Fine-Gray P = .018). The 15-year cumulative incidence of prostate cancer-specific mortality was 6.2% versus 3.2%, respectively, (sHR, 0.52; 95% CI, 0.27-0.98; Fine-Gray P = .045). There were no differences in overall survival (HR, 1.10; 95% CI, 0.84-1.45; log rank P = .469) or other-cause survival (sHR, 1.33; 95% CI, 0.99-1.79; Fine-Gray P = .061). Salvage therapy was more common in the 70 Gy arm, at 38.7% versus 21.9% in the 78 Gy arm (P = .002). There was a 2.3% secondary solid malignancy rate (1 bladder, 6 rectal) within the radiation treatment field, which was not significantly different between treatment arms.

CONCLUSIONS

Dose escalation by 8 Gy (78 Gy vs 70 Gy) provided a sustained improvement in biochemical and clinical failure, which translated into lower salvage rates and improved prostate cancer-specific mortality, but not overall survival. Long-term follow-up demonstrated a low incidence of potential solid tumor secondary malignancies.

Use of three pins in Gamma Knife stereotactic radiosurgery for brain metastases

PURPOSE

We present our institutional experience in treating brain metastases with GK-SRS and a headframe fixed to the skull with only 3 pins to avoid collisions between the headframe and the Gamma Knife (GK) machine.

METHODS AND MATERIALS

Among 3500 consecutive patients who received GK-SRS in 2011-2017, 50 had 1 of the 2 anterior pins removed immediately before treatment of ≥1 brain lesion. Endpoints were local control, dosimetric parameters, and toxicity.

RESULTS

Median follow-up time for the 49 patients with follow-up was 7.0 months (range 0.2-57.0). Median number of lesions treated per session was 6 (range 1-18); a median 1 lesion was treated with 3-pin fixation (range 1-2) and a median 5 lesions treated with 4-pin fixation (range 0-17) during the same session. Lesions treated with 3-pin fixation were in the occipital lobe (n=41), cerebellum (n=9), or temporal lobe (n=1). No local failures were noted. The sole grade 2 toxicity (partial seizure) was attributed to treatment of a 4-pin-fixed lesion. Except for gradient index, dosimetry did not vary for lesions treated with 3-pin versus 4-pin fixation.

CONCLUSIONS

Treating brain metastases with 3-pin fixation did not compromise treatment outcome and is a good option for posterior brain metastases that cannot otherwise be treated with 4-pin GK-SRS.

Outcomes of re-irradiation for brain recurrence after prophylactic or therapeutic whole-brain irradiation for small cell lung Cancer: a retrospective analysis

Background

Small cell lung cancer (SCLC) can recur in the brain after whole-brain irradiation (WBI). We documented outcomes after treatment of such recurrences and sought predictors of local control and overall survival (OS).

Materials and methods

Eighty-five patients with SCLC and brain recurrence after prophylactic or therapeutic WBI in 1998–2015 were identified and data were extracted from the medical records. Survival was estimated with the Kaplan-Meier method, and univariate and multivariate Cox proportional hazards modeling was used to identify factors associated with OS or further brain progression.

Results

Brain recurrence was treated by stereotactic radiosurgery (SRS) in 33 patients (39%), repeat WBI in 14 (16%), chemotherapy-only in 16 (19%), and observation in 22 (26%). Median OS time after brain recurrence (OSrec) was 4.3 months for all patients; 6-month OSrec rates were 58% after SRS, 21% after repeat WBI, 50% after chemotherapy-only, and 5% after observation (P < 0.001). Inferior OSrec was associated with poor performance status (ECOG score ≥ 3) and uncontrolled extracranial disease. Superior OSrec was associated with receipt of ≥4 chemotherapy cycles before brain recurrence and receipt of chemotherapy, SRS, or repeat WBI afterward. Receipt of chemotherapy after brain recurrence correlated with brain progression.

Conclusions

Some patients with brain recurrence after WBI for SCLC can survive for extended periods with appropriate intervention, especially those with adequate performance status or controlled extracranial disease.

Outcomes After Hypofractionated Dose-Escalation using a Simultaneous Integrated Boost Technique for Treatment of Spine Metastases Not Amenable to Stereotactic Radiosurgery

PURPOSE

Spine stereotactic radiosurgery delivers an ablative dose of radiation therapy (RT) with high conformity relative to standard fractionated RT. This technique is suboptimal for extended targets (>3 vertebral levels) owing to treatment alignment concerns or for patients with marked epidural extension. In these patients, we hypothesized that use of hypofractionated intensity modulated RT/volumetric modulated arc therapy to dose escalate the gross tumor volume (GTV) to 40 Gy as a spinal simultaneous integrated boost (SSIB) would allow for durable local control and palliation.

METHODS AND MATERIALS

We retrospectively analyzed 15 separate spinal sites (12 patients) that were treated with the SSIB technique between 2012 and 2016. The GTV and clinical target volume were prescribed at 40 Gy and 30 Gy, respectively, in 10 fractions. The spinal cord was allowed a maximum point dose of 34 Gy. The GTV was defined as gross tumor. The clinical target volume encompassed the GTV in addition to the involved vertebral bodies, at-risk paraspinal space, and spinal canal, followed by a planning target volume expansion of 3 to 5 mm.

RESULTS

The median follow-up for patients in our cohort was 17 months. At 1 year, local control was 93%, and overall survival was 58%, with a median time to death after treatment of 7 months. No grade ≥2 neurologic toxicities were reported for any of the patients. Nine of 12 patients had pain at presentation, of which 7 patients (78%) reported improvement and/or complete resolution of their pain after treatment.

CONCLUSIONS

Our early experience using a dose of 40 Gy to the GTV delivered via an SSIB technique, in lieu of spine stereotactic radiation surgery but more aggressive than conventional palliative doses, provides durable local control and pain relief. This technique may allow for improved local control and palliation in patients with radioresistant disease compared with conventional 3-dimensional conformal fractionated RT.

Randomized Trial of Hypofractionated, Dose-Escalated, Intensity-Modulated Radiation Therapy (IMRT) Versus Conventionally Fractionated IMRT for Localized Prostate Cancer

PURPOSE

Hypofractionated radiotherapy delivers larger daily doses of radiation and may increase the biologically effective dose delivered to the prostate. We conducted a randomized trial testing the hypothesis that dose-escalated, moderately hypofractionated intensity-modulated radiation therapy (HIMRT) improves prostate cancer control compared with conventionally fractionated IMRT (CIMRT) for men with localized prostate cancer.

PATIENTS AND METHODS

Men were randomly assigned to 75.6 Gy in 1.8-Gy fractions delivered over 8.4 weeks (CIMRT) or 72 Gy in 2.4 Gy fractions delivered over 6 weeks (HIMRT, biologically equivalent to 85 Gy in 1.8-Gy fractions assuming prostate cancer α-to-β ratio of 1.5). Failure was defined as prostate-specific antigen (PSA) failure (nadir plus 2 ng/mL) or initiation of salvage therapy. Modified Radiation Therapy Oncology Group criteria were used to grade late (≥ 90 days after completion of radiotherapy) GI and genitourinary toxicity.

RESULTS

Most of the 206 men (72%) had cT1, Gleason score 6 or 7 (99%), and PSA level ≤ 10 ng/mL (90%) disease. Androgen deprivation therapy was received by 24%. With a median follow-up of 8.5 years, men treated with HIMRT experienced fewer treatment failures (n = 10) than men treated with CIMRT (n = 21; P = .036). The 8-year failure rate was 10.7% (95% CI, 5.8% to 19.1%) with HIMRT and 15.4% (95% CI, 9.1% to 25.4%) with CIMRT. There was no difference in overall survival ( P = .39). There was a nonsignificant increase in late grade 2 or 3 GI toxicity with HIMRT (8-year 5.0% v 12.6%; P = .08). However, GI toxicity was only 8.6% when rectal volume receiving 65 Gy of HIMRT was ≤ 15%. Late genitourinary toxicity was similar ( P = .84). There was no grade 4 toxicity.

CONCLUSION

The results of this randomized trial demonstrate superior cancer control for men with localized prostate cancer who receive dose-escalated moderately hypofractionation radiotherapy while shortening treatment duration.

Outcomes of patients in the national cancer database treated non-surgically for localized rectal cancer

Background

Some patients undergo a non-operative approach to localized rectal adenocarcinoma either because they decline surgery or because their medical comorbidities preclude surgical intervention. Published studies reporting excellent outcomes with a "wait-and-see" approach have been small and highly-selected. We aimed to analyze survival outcomes and prognostic factors for patients with localized rectal adenocarcinoma in the National Cancer Database (NCDB) undergoing definitive radiation without surgical intervention.

Methods

The NCDB was queried for patients with non-metastatic rectal adenocarcinoma treated with definitive radiotherapy who did not undergo a surgical resection either because the patient refused surgery, surgery was medically contraindicated, or surgery was otherwise unplanned. Patient, tumor and treatment-related characteristics were compared between those treated with 45-50.3 Gray (Gy), 50.4-54 Gy and >54 Gy. Survivals were compared using the Log-Rank test. Univariate and multivariate Cox regression analyses were performed. Survivals were then compared utilizing a robust inverse-probability-weighted regression adjustment method with nearest-neighbor matching.

Results

Eight thousand four hundred and eight patients were included for analysis. After case-matching and adjusting for significant prognostic factors, patients receiving 50.4-54 Gy had a significantly longer median, 1- and 5-year overall survival (OS) (49.4 months, 85.8%, 44.7%) compared with patients receiving 45-50.3 or >54 Gy (37.2 months, 79.2%, 38.4% and 34.2 months, 84.5%, 35.3%, respectively; Log rank P value <0.0001).

Conclusions

In an unselected group of patients treated at NCDB-participating institutions, survival rates with a non-surgical approach to non-metastatic rectal adenocarcinoma are much lower than those reported in well-selected single-institutional studies. Moderate dose escalation from 50.4-54 Gy was associated with better OS compared with doses <50.4 Gy or >54 Gy after adjusting for significant covariant.

Twice-daily Thoracic Radiotherapy for Limited-stage Small-cell Lung Cancer Does Not Increase the Incidence of Acute Severe Esophagitis

PURPOSE

Acute esophagitis is common after thoracic radiation therapy (TRT) given with chemotherapy for limited-stage small-cell lung cancer (LS SCLC). Although twice-daily TRT to 45 Gy in 30 fractions is considered standard, some clinicians are reluctant to use this schedule because of its perceived impracticality and risk of severe esophagitis. We reviewed a single-institution experience with severe (grade ≥ 3) esophagitis after TRT with chemotherapy for LS SCLC.

PATIENTS AND METHODS

A total of 504 patients were identified as having received TRT (≥45 Gy) with platinum-containing chemotherapy for LS SCLC at MD Anderson Cancer Center in 1987 through 2012. Patients with complete or good partial response were offered prophylactic cranial irradiation. Esophagitis was scored retrospectively with the Common Terminology Criteria for Adverse Events, V3.0. Clinical variables were analyzed for possible association with acute grade ≥ 3 esophagitis.

RESULTS

At a median follow-up time of 23.9 months (range, 1.2-240.8 months), 103 (20%) patients had experienced grade ≥ 3 esophagitis. In univariate analysis, TRT dose ≥ 60 Gy was the only factor associated with severe esophagitis (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.02-3.30; P = .043); use of twice-daily TRT was not (OR, 0.96; 95% CI, 0.61-1.52; P = .867). The significance of TRT to ≥ 60 Gy was maintained in multivariate Cox regression analysis adjusted for tumor size (OR, 1.91; 95% CI, 1.05-3.46; P = .034).

CONCLUSIONS

TRT to ≥ 60 Gy predicted acute severe esophagitis, but twice-daily fractionation did not. Standard-dose 45-Gy twice-daily TRT should not be avoided for fear of severe esophagitis.

Addition of Definitive Radiotherapy to Chemotherapy in Patients With Newly Diagnosed Metastatic Nasopharyngeal Cancer

Background: Management of metastatic (M1) nasopharyngeal cancer (NPC) is controversial; data suggest high overall survival (OS) rates with definitive chemoradiotherapy (CRT). Herein, we evaluated OS in patients with M1 NPC undergoing chemotherapy alone versus CRT. Methods: The National Cancer Data Base was queried for M1 NPC cases. Patients undergoing no/unknown chemotherapy and/or with unknown/nondefinitive radiotherapy (RT) doses (<60 Gy) were excluded. Logistic regression analysis ascertained clinical factors associated with RT administration. Kaplan-Meier analysis evaluated OS between both cohorts; Cox proportional hazards modeling assessed factors associated with OS. Survival was then evaluated between matched populations using inverse-probability-weighted regression adjustment. OS between groups was also measured in patients surviving ≥1 and ≥3 years to address bias from poor-prognostic subsets (eg, widely disseminated disease), and those receiving CRT ≤30 and ≤60 days of each other (surrogates for concurrent CRT) versus >30 and >60 days (sequential) of each other. Results: Of 555 patients, 296 (53%) received chemotherapy alone and 259 (47%) underwent CRT. Patients undergoing CRT more often had private insurance (P=.001) and lived in areas with higher education levels (P=.028). Median OS in the chemotherapy-only and CRT cohorts were 13.7 and 25.8 months, respectively (P<.001); differences persisted between matched populations (P<.001). On multivariate analysis, receipt of additional RT independently predicted for improved OS (P<.001). OS differences between cohorts remained apparent when evaluating patients surviving for ≥1 (P<.001) and ≥3 (P=.002) years. Patients who received concurrent or sequential CRT displayed improved OS over those receiving chemotherapy alone, for both the 30-day (P<.001) and 60-day cutoffs (P<.001). Conclusions: Patients with M1 NPC undergoing definitive RT and chemotherapy experienced higher survival than those receiving chemotherapy alone. Risk stratification and patient selection for such combined modality interventions is critical.

Early-stage mantle cell lymphoma: a retrospective analysis from the International Lymphoma Radiation Oncology Group (ILROG)

Background

Mantle cell lymphoma (MCL) rarely presents as early-stage disease, but clinical observations suggest that patients who present with early-stage disease may have better outcomes than those with advanced-stage disease.

Patients and methods

In this 13-institution study, we examined outcomes among 179 patients with early-stage (stage I or II) MCL in an attempt to identify prognostic factors that influence treatment selection and outcome. Variables examined included clinical characteristics, treatment modality, response to therapy, sites of failure, and survival.

Results

Patients were predominantly male (78%) with head and neck being the most common presenting sites (75%). Most failures occurred outside the original disease site (79%). Although the administration of radiation therapy, either alone or with chemotherapy, reduced the risk of local failure, it did not translate into an improved freedom from progression or overall survival (OS). The treatment outcomes were independent of treatment modality. The 10-year OS for patients treated with chemotherapy alone, chemo-radiation therapy and radiation therapy alone were 69%, 62%, and 74% (P = 0.79), and the 10-year freedom from progression were 46%, 43%, and 31% (P = 0.64), respectively.

Conclusion

Given the excellent OS rates regardless of initial therapy in patients with early-stage MCL, de-intensified therapy to limit treatment-related toxicity is a reasonable approach.

Treatment at a high-volume centre is associated with improved survival among patients with non-metastatic hepatocellular carcinoma

BACKGROUND & AIMS

The association between case volume and outcomes is well-documented for several cancer types. However, it is unknown if patients with hepatocellular carcinoma treated at high-volume centres have improved overall survival.

METHODS

About 135 442 patients diagnosed with hepatocellular carcinoma between 2004-2014 were identified in the Commission on Cancer's National Cancer Database and 53 795 patients were excluded for metastatic or node-positive disease. Average annual case volume was calculated as the total number of cases treated per centre from 2004-2014 and dividing by 10. Receiver operating characteristic curves showed the most significant case number threshold between high-volume centres and remaining centres. Univariate and multivariate analyses were performed using Cox regression analysis to determine factors associated with improved survival. Kaplan-Meier curves and log-rank tests were used for overall survival estimates.

RESULTS

A total of 81 647 patients with stage I-III hepatocellular carcinoma were treated at a total of 1218 centres. The median [range] case volume per year averaged over the 10-year study period was 48.6 [0.1-205.5]. High-volume centres treated >114 cases of hepatocellular carcinoma annually while remaining centre treated ≤114 cases. Median survival for patients treated in high-volume centres and remaining centres were 31.9 and 16.6 months respectively (Log Rank P < .001). On multivariate analysis, average annual case volume was significantly associated with improved survival.

CONCLUSIONS

Receiving treatment at a high-volume centre is significantly associated with survival for patients with non-metastatic disease. Improved survival at high-volume centres may be related to access to a variety of treatment modalities, multidisciplinary evaluation, and/or subspecialty expertise.

Outcomes of stereotactic radiosurgery of brain metastases from neuroendocrine tumors

Background

Stereotactic radiosurgery (SRS) is an established treatment for brain metastases, yet little is known about SRS for neuroendocrine tumors given their unique natural history.

Objective

To determine outcomes and toxicity from SRS in patients with brain metastases arising from neuroendocrine tumors.

Methods

Thirty-three patients with brain metastases from neuroendocrine tumors who underwent SRS were retrospectively reviewed. Median age was 61 years and median Karnofsky performance status was 80. Primary sites were lung (87.9%), cervix (6.1%), esophagus (3%), and prostate (3%). Ten patients (30.3%) received upfront SRS, 7 of whom had neuroendocrine tumors other than small cell lung carcinoma. Kaplan-Meier survival and Cox regression analyses were performed to determine prognostic factors for survival.

Results

With median follow-up after SRS of 5.3 months, local and distant brain recurrence developed in 5 patients (16.7%) and 20 patients (66.7%), respectively. Median overall survival (OS) after SRS was 6.9 months. Patients with progressive disease per Response Assessment in Neuro-Oncology-Brain Metastases (RANO-BM) criteria at 4 to 6 weeks after SRS had shorter median time to developing recurrence at a distant site in the brain and shorter OS than patients without progressive disease: 1.4 months and 3.3 months vs 11.4 months and 12 months, respectively (both P < .001). Toxicity was more likely in lesions of small cell histology than in lesions of other neuroendocrine tumor histology, 15.7% vs 3.3% (P = .021). No cases of grade 3 to 5 necrosis occurred.

Conclusions

SRS is an effective treatment option for patients with brain metastases from neuroendocrine tumors with excellent local control despite slightly higher toxicity rates than expected. Progressive disease at 4 to 6 weeks after SRS portends a poor prognosis.

Prognostic significance of pretreatment total lymphocyte count and neutrophil-to-lymphocyte ratio in extensive-stage small-cell lung cancer

BACKGROUND

We evaluated pretreatment total lymphocyte count (TLC, marker of immunosuppression), neutrophil-to-lymphocyte ratio (NLR, marker of inflammation), and overall survival (OS) in patients with extensive-stage small-cell lung cancer (ES-SCLC).

METHODS

Pretreatment blood characteristics, age, sex, performance status, race, stage (M1a vs. M1b), number and location of metastases, weight loss, smoking status, chemotherapy cycles (<4 vs. ≥4), thoracic radiotherapy dose (<45 vs. ≥45 Gy), and receipt of prophylactic cranial irradiation (PCI) were evaluated in 252 patients with ES-SCLC treated in 1998-2015. Factors significant in univariate analysis were selected as covariates for a multivariate Cox model.

RESULTS

Pretreatment TLC was below normal (<1.0 × 10³/µL) in 58 patients (23%). Median OS time was 11.0 months and was worse for those with TLC ≤ 1.5 × 10³/µL (9.8 vs. 12.0 months) and pretreatment NLR > 4.0 (9.4 vs. 13.9 months). Multivariate analysis identified low TLC (hazard ratio [HR] 0.734, 95% confidence interval [CI] 0.565-0.955, P = 0.021) and high NLR (HR 1.521, 95% CI 1.172-1.976, P = 0.002) as predicting inferior survival. Age (>63 y), sex (male), performance status (≥2), chemotherapy cycles (<4), radiation dose (<45 Gy), and no PCI also predicted worse OS (P < 0.05).

CONCLUSIONS

Pretreatment TLC and NLR may be useful for stratifying patients with ES-SCLC for treatment approaches.

Analysis of pseudoprogression after proton or photon therapy of 99 patients with low grade and anaplastic glioma

•

No difference in pseudoprogression rate six months after proton or photon therapy.

•

Oligodendrogliomas develop pseudoprogression sooner after protons vs. photons.

•

Astrocytomas develop pseudoprogression at similar time after protons vs. photons.

Background and purpose

Proton therapy is increasingly used to treat primary brain tumors. There is concern for higher rates of pseudoprogression (PsP) after protons compared to photons. The purposes of this study are to compare the rate of PsP after proton vs. photon therapy for grade II and III gliomas and to identify factors associated with the development of PsP.

Materials and methods

Ninety-nine patients age >18 years with grade II or III glioma treated with photons or protons were retrospectively reviewed. Demographic data, IDH and 1p19q status, and treatment factors were analyzed for association with PsP, progression free survival (PFS), and overall survival (OS).

Results

Sixty-five patients were treated with photons and 34 with protons. Among those with oligodendroglioma, PsP developed in 6/42 photon-treated patients (14.3%) and 4/25 proton-treated patients (16%, p = 1.00). Among those with astrocytoma, PsP developed in 3/23 photon-treated patients (13%) and 1/9 proton-treated patients (11.1%, p = 1.00). There was no difference in PsP rate based on radiation type, radiation dose, tumor grade, 1p19q codeletion, or IDH status. PsP occurred earlier in oligodendroglioma patients treated with protons compared to photons, 48 days vs. 131 days, p < .01. On multivariate analyses, gross total resection (p = .03, HR = 0.48, 95%CI = 0.25–0.93) and PsP (p = .04, HR = 0.22, 95% CI = 0.05–0.91) were associated with better PFS; IDH mutation was associated with better OS (p < .01, HR = 0.22, 95%CI = 0.08–0.65).

Conclusions

Patients with oligodendroglioma but not astrocytoma develop PsP earlier after protons compared to photons. PsP was associated with better PFS.

Bayesian Adaptive Randomization Trial of Passive Scattering Proton Therapy and Intensity-Modulated Photon Radiotherapy for Locally Advanced Non-Small-Cell Lung Cancer

Purpose This randomized trial compared outcomes of passive scattering proton therapy (PSPT) versus intensity-modulated (photon) radiotherapy (IMRT), both with concurrent chemotherapy, for inoperable non-small-cell lung cancer (NSCLC). We hypothesized that PSPT exposes less lung tissue to radiation than IMRT and thereby reduces toxicity without compromising tumor control. The primary end points were grade ≥ 3 radiation pneumonitis (RP) and local failure (LF). Patients and Methods Eligible patients had stage IIB to IIIB NSCLC (or stage IV NSCLC with a single brain metastasis or recurrent lung or mediastinal disease after surgery) who were candidates for concurrent chemoradiation therapy. Pairs of treatment plans for IMRT and PSPT were created for each patient. Patients were eligible for random assignment only if both plans satisfied the same prespecified dose-volume constraints for at-risk organs at the same tumor dose. Results Compared with IMRT (n = 92), PSPT (n = 57) exposed less lung tissue to doses of 5 to 10 Gy(RBE), which is the absorbed Gy dose multiplied by the relative biologic effectiveness (RBE) factor for protons; exposed more lung tissue to ≥ 20 Gy(RBE), but exposed less heart tissue at all dose levels between 5 and 80 Gy(RBE). The grade ≥ 3 RP rate for all patients was 8.1% (IMRT, 6.5%; PSPT, 10.5%); corresponding LF rates were 10.7% (all), 10.9% (IMRT), and 10.5% (PSPT). The posterior probability of IMRT being better than PSPT was 0.54. Exploratory analysis showed that the RP and LF rates at 12 months for patients enrolled before versus after the trial midpoint were 21.1% (before) versus 18.2% (after) for the IMRT group (P = .047) and 31.0% (before) versus 13.1% (after) for the PSPT group (P = .027). Conclusion PSPT did not improve dose-volume indices for lung but did for heart. No benefit was noted in RP or LF after PSPT. Improvements in both end points were observed over the course of the trial.

Outcomes of Stereotactic Body Radiotherapy for T1-T2N0 Small Cell Carcinoma According to Addition of Chemotherapy and Prophylactic Cranial Irradiation: A Multicenter Analysis

BACKGROUND

Although T1-T2N0 non-small cell lung cancer can be managed with stereotactic body radiotherapy (SBRT) alone, this management has often been extrapolated to T1-T2N0 small cell lung cancer (SCLC). This secondary analysis of a multi-institutional cohort study investigated whether the addition of chemotherapy and prophylactic cranial irradiation (PCI) improved the outcomes for these patients.

MATERIALS AND METHODS

All cases of histologically confirmed T1-T2N0M0 SCLC were obtained from 24 institutions' prospectively collected SBRT databases. The clinical and treatment characteristics, toxicities, outcomes, and patterns of failure were assessed. We used Kaplan-Meier analysis to evaluate the survival outcomes. Univariate and multivariate analyses identified the predictors of outcomes.

RESULTS

From 24 institutions, 76 lesions were treated in 74 patients (median follow-up, 18 months). Chemotherapy and PCI were delivered in 56% and 23% of cases, respectively. The median SBRT dose per fraction was 50 Gy/5 fractions. Patients receiving chemotherapy experienced increased median disease-free survival (61.3 vs. 9.0 months; P = .02) and overall survival (31.4 vs. 14.3 months; P = .02). Chemotherapy independently predicted for better outcomes for disease-free survival and overall survival on multivariate analysis (P = .01). Toxicities were uncommon; 5.2% experienced grade ≥ 2 pneumonitis. Post-treatment failures were most commonly distant (45.8% of recurrences), followed by nodal (25.0%), and elsewhere in the lung (20.8%). The median time to each was 5 to 7 months.

CONCLUSION

Patients undergoing primary SBRT for T1-T2N0 SCLC should also undergo additional chemotherapy. No established role was found for PCI in this population.

Craniospinal irradiation prior to stem cell transplant for hematologic malignancies with CNS involvement: Effectiveness and toxicity after photon or proton treatment

PURPOSE/OBJECTIVE(S)

Craniospinal irradiation (CSI) improves local control of leukemia/lymphoma with central nervous system (CNS) involvement; however, for adult patients anticipating stem cell transplant (SCT), cumulative treatment toxicity is a major concern. We evaluated toxicities and outcomes for patients receiving proton or photon CSI before SCT.

METHODS AND MATERIALS

We identified 37 consecutive leukemia/lymphoma patients with CNS involvement who received CSI before SCT at our institution. Photon versus proton toxicities during CSI, transplant, and through 100 days posttransplant were compared using Fisher exact and Wilcoxon rank sum tests. Long-term neurotoxicity, disease response, and overall survival were analyzed.

RESULTS

Thirty-seven patients (23 photon, 14 proton) underwent CSI for CNS involvement of acute lymphoblastic leukemia (49%), acute myeloblastic leukemia (22%), chronic lymphocytic leukemia (3%), chronic myelocytic leukemia (14%), lymphoma (11%), and myeloma (3%). CSI was used for consolidation (30 patients, 81%) and gross disease treatment (7 patients, 19%). Median radiation dose (interquartile range) was 24 Gy (23.4-24) for photons and 21.8 Gy (21.3-23.6) for protons (P = .03). Proton CSI was associated with lower rates of Radiation Therapy Oncology Group grade 1-3 mucositis during CSI (7% vs 44%, P = .03): 1 grade 3 with protons versus 5 grade 1, 3 grade 2, and 2 grade 3 with photons. During CSI, other toxicities (infection, gastrointestinal symptoms) did not differ. Allogeneic stem cell transplant (SCT) was used in 95% of patients, with 53% of patients in remission before SCT. Myeloablative conditioning was used for 76%. During SCT admission and 100 days post-SCT, toxicities did not differ by CSI technique. Successful engraftment occurred in 95% of patients (P = .67). Progression or death occurred for 47% of patients, with only 1 CNS relapse.

CONCLUSION

In our cohort, CSI offered excellent local control for CNS-involved hematologic malignancies in the pre-SCT setting. Acute mucositis occurred less frequently with proton CSI with comparable peritransplant/long-term toxicity profile, suggesting the need to further explore the benefit/toxicity profile of this technique.

Evaluating Factors for Prophylactic Feeding Tube Placement in Gastroesophageal Cancer Patients Undergoing Chemoradiotherapy

PURPOSE

Though better studied in head/neck cancers, there are currently no studies on timing of feeding tube (FT) placement in patients with gastroesophageal cancer. This study sought to discern characteristics of patients who used versus did not use a prophylactic FT (pFT), and also analyzed factors associated with placement of FTs during chemoradiotherapy (CRT).

METHODS/MATERIALS

From 1998 to 2013, 1,329 patients underwent neoadjuvant CRT, of which 323 received an FT. Patients for whom FTs were placed prior to treatment due to tumor occlusion or substantial weight loss (n = 130), and those with FTs placed following treatment (n = 43) were excluded. One hundred patients had pFTs placed, and 50 underwent placement during CRT. The following was collected for each patient: demographic/patient information, oncologic/treatment characteristics, and CRT tolerance.

RESULTS

No significant differences were found in any parameter between cohorts that used (n = 66) versus did not use a pFT (n = 34); on univariate and multivariate analyses, no pretreatment characteristic associated with using a pFT. When compared with patients who used a pFT (n = 66), those who required an FT during CRT (n = 50) had lower body mass index (p = 0.045), underwent higher-dose radiotherapy (p = 0.003), and received induction chemotherapy (p = 0.031). On multivariate analysis, receipt of induction chemotherapy and greater weight loss and esophagitis during treatment were associated with placement of FTs during CRT (p < 0.05).

CONCLUSION

Of our cohort who received pFTs, there were no clinical factors that predicted for their use. Patients must be closely monitored for weight loss and esophagitis when receiving CRT in order to intervene prior to further worsening of toxicities.

Heterogeneity in Treatment Response of Spine Metastases to Spine Stereotactic Radiosurgery Within "Radiosensitive" Subtypes

PURPOSE

To characterize outcomes of metastatic colorectal and non-small cell lung cancer (NSCLC) histologies, compared with other radiosensitive histologies, treated with spine stereotactic radiosurgery with regard to local control, overall survival, and predictors of response.

METHODS AND MATERIALS

A total of 127 patients with 148 spine stereotactic radiosurgery-treated metastatic lesions at our institution between 2003 and 2013 were reviewed. We assessed clinical endpoints in relation to histologic type, including local control (LC) and overall survival (OS), using univariate and multivariate analyses.

RESULTS

For all patients, the 1- and 2-year actuarial rates for LC were 82.6% and 75.8%, and rates for OS were 72.9% and 51.5% respectively. Among tumor histologies, 1-year cumulative incidence rates of local failure for thyroid, breast, lung, and colon cancer were 8.7%, 7.0%, 26.6%, and 39.6%, respectively. When analyzed together, NSCLC and colorectal cancers had significantly greater cumulative incidence rates at 1 and 2 years (30.4% and 38.7%, respectively) than other histologies (8.0% and 14.1% respectively, P=.0008). Non-small cell lung cancer/colorectal tumor status was a significant predictor of local failure in a competing risk univariate model (hazard ratio 2.12, 95% confidence interval 1.07-4.17, P=.03) and multivariate model (hazard ratio 2.35, 95% confidence interval 1.12-4.92, P=.024).

CONCLUSIONS

Spine stereotactic radiosurgery is an effective strategy in achieving local control of spine metastases, particularly among radiosensitive histologies. However, a subset of these classically defined histologies (NSCLC and colorectal) has a propensity toward local failure. In addition to resulting in poorer OS outcomes, the poor LC rates seen in NSCLC and colorectal cancers in this study are more consistent with a radioresistant phenotype, suggesting the need for optimized dosing regimens in this subgroup.

Spine stereotactic radiosurgery for metastatic sarcoma: patterns of failure and radiation treatment volume considerations

OBJECTIVE

Given the relatively lower radiosensitivity of sarcomas and the locally infiltrative patterns of spread, the authors sought to investigate spine stereotactic radiosurgery (SSRS) outcomes for metastatic sarcomas and to analyze patterns of failure.

METHODS

The records of 48 patients with 66 sarcoma spinal metastases consecutively treated with SSRS between 2002 and 2013 were reviewed. The Kaplan-Meier method was used to estimate rates of overall survival (OS) and local control (LC). Local recurrences were categorized as occurring infield (within the 95% isodose line [IDL]), marginally (between the 20% and 95% IDLs), or out of field.

RESULTS

Median follow-up time was 19 months (range 1–121 months), and median age was 53 years (range 17–85 years). The most commonly treated histology was leiomyosarcoma (42%). Approximately two-thirds of the patients were treated with definitive SSRS (44 [67%]) versus postoperatively (22 [33%]). The actuarial 1-year OS and LC rates were 67% and 81%, respectively. Eighteen patients had a local relapse, which was more significantly associated with postoperative SSRS (p = 0.04). On multivariate modeling, receipt of postoperative SSRS neared significance for poorer LC (p = 0.06, subhazard ratio [SHR] 2.33), while only 2 covariates emerged as significantly correlated with LC: 1) biological equivalent dose (BED) > 48 Gy (vs BED ≤ 48 Gy, p = 0.006, SHR 0.21) and 2) single vertebral body involvement (vs multiple bodies, p = 0.03, SHR 0.27). Of the 18 local recurrences, 14 (78%) occurred at the margin, and while the majority of these cases relapsed within the epidural space, 4 relapsed within the paraspinal soft tissue. In addition, 1 relapse occurred out of field. Finally, the most common acute toxicity was fatigue (15 cases), with few late toxicities (4 insufficiency fractures, 3 neuropathies).

CONCLUSIONS

For metastatic sarcomas, SSRS provides durable tumor control with minimal toxicity. High-dose single-fraction regimens offer optimal LC, and given the infiltrative nature of sarcomas, when paraspinal soft tissues are involved, larger treatment volumes may be warranted.

Proton Beam Radiotherapy and Concurrent Chemotherapy for Unresectable Stage III Non-Small Cell Lung Cancer: Final Results of a Phase 2 Study

Importance

Proton beam radiotherapy (PBT) has the potential to reduce toxic effects in the definitive management of locally advanced non-small cell lung cancer (NSCLC), but long-term prospective data are lacking.

Objective

To report the final (5-year) results of a prospective study evaluating concurrent chemotherapy and high-dose PBT to treat unresectable stage III NSCLC.

Design, Setting, and Participants

In this open-label, single-group assignment study, with median follow-up of 27.3 months for all patients and 79.6 months for survivors, 64 patients were enrolled and analyzed; inclusion criteria were unresectable IIIA/IIIB histologically confirmed NSCLC, Karnofsky performance status 70 to 100, and 6-month prediagnosis weight loss of no more than 10%. Staging used positron emission tomography and/or computed tomography. Induction chemotherapy was allowed.

Interventions

Concurrent chemotherapy (carboplatin-paclitaxel) and passively scattered PBT (74-Gy relative biological effectiveness) in all patients.

Main Outcomes and Measures

Kaplan-Meier analysis of overall survival (OS), progression-free survival (PFS), actuarial distant metastasis, and locoregional recurrence. Patterns of treatment failure were categorized as local/regional or distant. Acute and late toxic effects were prospectively assigned using Common Terminology Criteria for Adverse Events, v3.0.

Results

Of 64 patients (22 [34%] female; median [range] age, 70 [37-78] years; stage IIIA, 30 [47%]; IIIB, 34 [53%]), 17 (27%) were alive at last follow-up. Median OS was 26.5 months (5-year OS, 29%; 95% CI, 18%-41%). Five-year PFS was 22% (95% CI, 12%-32%); 5-year actuarial distant metastasis and locoregional recurrence were 54% (n = 36) and 28% (n = 22), respectively. Treatment failures were largely (31 [48%] patients) distant, with low rates of crude local (10 [16%]) and regional (9 [14%]) recurrences. Rates of grade 2 and 3 acute esophagitis were 18 (28%) and 5 (8%), respectively. Acute grade 2 pneumonitis occurred in 1 (2%) patient. Late toxic effects were uncommon: 1 (2%) patient developed an esophageal stricture (grade 2) and 1 (2%) grade 4 esophagitis. Late grades 2 and 3 pneumonitis occurred in 10 (16%) and 8 (12%), respectively. Two (3%) patients developed a bronchial stricture (grade 2), and 1 (2%) a grade 4 bronchial fistula. There were no acute or late grade 5 toxic effects.

Conclusions and Relevance

Concurrent chemotherapy and PBT to treat unresectable NSCLC afford promising clinical outcomes and rates of toxic effects compared with historical photon therapy data. Further optimization of proton therapy, particularly intensity-modulated proton therapy, is still needed.

Incidence of Second Malignancy after Successful Treatment of Limited-Stage Small-Cell Lung Cancer and Its Effects on Survival

INTRODUCTION

Extended survival outcomes from improved treatments for patients with cancer come with an increased risk for development of a metachronous second malignancy (MSM). We evaluated the incidence of MSM after successful treatment of SCLC and compared survival between patients with SCLC in whom MSM developed and those in whom it did not.

METHODS

Selection criteria were a diagnosis of limited-stage SCLC and receipt of at least 45 Gy of radiotherapy and chemotherapy at a single institution in 1985-2012. MSM was defined as a tumor of a different histologic type than the primary that appeared more than 2 years after the diagnosis of SCLC.

RESULTS

Of 704 patients identified, 32 were excluded for lack of follow-up, 48 for having SCLC as MSM after treatment of another type of cancer, 37 for nonmelanoma skin cancer as MSM, and 46 for MSM within 2 years after SCLC diagnosis. Of the remaining 541 patients, 346 had recurrent SCLC, 180 had no second malignancy and no recurrence, and 15 (2.8%) had MSM (13 in a lung [eight adenocarcinomas and five squamous cell carcinomas], one sarcoma, and one acute myeloid leukemia). All 15 patients with MSM achieved complete response to the SCLC treatment. Overall survival was longer for patients with MSM than for patients with no other malignancies and no recurrence, with 10-year rates of 61.9% (95% confidence interval: 30.0%-82.6%) and 29.9% (95% confidence interval: 21.5%-38.6%), respectively (p = 0.03).

CONCLUSIONS

Long-term survivors after treatment for SCLC should be made aware of the risk for MSM and the necessity of follow-up.

Reirradiation of thoracic cancers with intensity modulated proton therapy

PURPOSE

Reirradiation of thoracic malignancies is a treatment challenge, with concerns for toxicity and the inability to deliver definitive doses. Intensity modulated proton therapy (IMPT) may allow safe delivery of a higher dose of radiation to the tumor while minimizing toxicities.

METHODS AND MATERIALS

Between 2011 and 2016, 27 patients who received IMPT for reirradiation of thoracic malignancies with definitive intent were retrospectively analyzed. Patients were included if they received a prior thoracic radiation course. All doses were recalculated to an equivalent dose in 2-Gy fractions (EQD2). Patients received IMPT to a median dose of 66 EQD2 Gy (range, 43.2-84 Gy) for recurrence of thoracic cancer (93%) or sequentially after a course of thoracic stereotactic ablative radiation therapy (7%).

RESULTS

Twenty-two patients (81%) were treated for non-small cell lung cancer. The median time to reirradiation was 29.5 months. At a median follow-up for all patients of 11.2 months (25.9 surviving patients), the median overall survival was 18.0 months, with a 1-year overall survival of 54%. Four patients (15%) experienced an in-field local failure (LF), with a 1-year freedom from LF rate of 78%. The 1-year freedom from locoregional failure and 1-year progression-free survival rates were 61% and 51%, respectively. Patients who received 66 EQD2 Gy or higher had improved 1-year freedom from LF (100% vs 49%; P = .013), 1-year freedom from locoregional failure (84% vs 23%; P = .035), and 1-year progression-free survival (76% vs 14%; P = .050). Reirradiation was well tolerated, with only 2 patients (7%) experiencing late grade 3 pulmonary toxicity, and none with grade 3 or higher esophagitis. There were no grade 4-5 toxicities.

CONCLUSIONS

These data represent the largest series of patients treated with IMPT for definitive reirradiation of thoracic cancers. They demonstrate that IMPT provided durable local control with minimal toxicity and suggest that higher doses may improve outcomes.

Radiation therapy improves survival in patients with testicular diffuse large B-cell lymphoma<sup/>

In 120 Stage I-IV testicular diffuse large B-cell lymphoma (DLBCL) patients treated from 1964 to 2015, we assessed the benefits of prophylactic contralateral testicular radiation (RT) and prophylactic central nervous system (CNS) therapy on overall, progression free, testicular relapse free, and CNS relapse free survival (OS, PFS, TRFS, and CRFS, respectively). Seventy percent of patients received RT, 53% received anthracyclines and rituximab (modern therapy), and 61% received CNS prophylaxis. On univariate analysis RT was associated with improved TRFS, PFS, and trended toward improved OS. On multivariate analysis (MVA), RT was significantly associated with improved OS and PFS; the PFS benefit persisted among patients receiving modern therapy. CNS prophylaxis was associated with improved OS, PFS, and TRFS, but not CRFS on univariate analysis, and was not significant on MVA. RT is associated with improved survival, and should be considered for all testicular DLBCL patients, but additional strategies are needed to prevent CNS relapse.

7-year follow-up after stereotactic ablative radiotherapy for patients with stage I non-small cell lung cancer: Results of a phase 2 clinical trial

BACKGROUND

The authors evaluated the efficacy, patterns of failure, and toxicity of stereotactic ablative radiotherapy (SABR) for patients with medically inoperable, clinical stage I non-small cell lung cancer (NSCLC) in a prospective clinical trial with 7 years of follow-up. Clinical staging was performed according to the seventh edition of the American Joint Committee on Cancer TNM staging system.

METHODS

Eligible patients with histologically confirmed NSCLC of clinical stage I as determined using positron emission tomography staging were treated with SABR (50 grays in 4 fractions). The primary endpoint was progression-free survival. Patients were followed with computed tomography and/or positron emission tomography/computed tomography every 3 months for the first 2 years, every 6 months for the next 3 years, and then annually thereafter.

RESULTS

A total of 65 patients were eligible for analysis. The median age of the patients was 71 years, and the median follow-up was 7.2 years. A total of 18 patients (27.7%) developed disease recurrence at a median of 14.5 months (range, 4.3-71.5 months) after SABR. Estimated incidences of local, regional, and distant disease recurrence using competing risk analysis were 8.1%, 10.9%, and 11.0%, respectively, at 5 years and 8.1%, 13.6%, and 13.8%, respectively, at 7 years. A second primary lung carcinoma developed in 12 patients (18.5%) at a median of 35 months (range, 5-67 months) after SABR. Estimated 5-year and 7-year progression-free survival rates were 49.5% and 38.2%, respectively; the corresponding overall survival rates were 55.7% and 47.5%, respectively. Three patients (4.6%) experienced grade 3 treatment-related adverse events. No patients developed grade 4 or 5 adverse events (toxicity was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 3.0]).

CONCLUSIONS

With long-term follow-up, the results of the current prospective study demonstrated outstanding local control and low toxicity after SABR in patients with clinical stage I NSCLC. Regional disease recurrence and distant metastases were the dominant manifestations of failure. Surveillance for second primary lung carcinoma is recommended. Cancer 2017;123:3031-39. © 2017 American Cancer Society.

Insurance Status and Racial Disparities in Cancer-Specific Mortality in the United States: A Population-Based Analysis

Background: Cancer-specific mortality (CSM) is known to be higher among blacks and lower among Hispanics compared with whites. Private insurance confers CSM benefit, but few studies have examined the relationship between insurance status and racial disparities. We sought to determine differences in CSM between races within insurance subgroups.Methods: A population-based cohort of 577,716 patients age 18 to 64 years diagnosed with one of the 10 solid malignancies causing the greatest mortality over 2007 to 2012 were obtained from Surveillance, Epidemiology, and End Results. A Cox proportional hazards model for CSM was constructed to adjust for known prognostic factors, and interaction analysis between race and insurance was performed to generate stratum-specific HRs.Results: Blacks had similar CSM to whites among the uninsured [HR = 1.01; 95% confidence interval (CI), 0.96-1.05], but higher CSM among the Medicaid (HR = 1.04; 95% CI, 0.01-1.07) and non-Medicaid (HR = 1.14; 95% CI, 1.12-1.16) strata. Hispanics had lower CSM compared with whites among uninsured (HR = 0.80; 95% CI, 0.76-0.85) and Medicaid (HR = 0.88; 95% CI, 0.85-0.91) patients, but there was no difference among non-Medicaid patients (HR = 0.99; 95% CI, 0.97-1.01). Asians had lower CSM compared with whites among all insurance types: uninsured (HR = 0.80; 95% CI, 0.76-0.85), Medicaid (HR = 0.81; 95% CI, 0.77-0.85), and non-Medicaid (HR = 0.85; 95% CI, 0.83-0.87).Conclusions: The disparity between blacks and whites was largest, and the advantage of Hispanic race was absent within the non-Medicaid subgroup.Impact: These findings suggest that whites derive greater benefit from private insurance than blacks and Hispanics. Further research is necessary to determine why this differential exists and how disparities can be improved. Cancer Epidemiol Biomarkers Prev; 26(6); 869-75. ©2017 AACR.

Multi-Institutional Experience of Stereotactic Ablative Radiation Therapy for Stage I Small Cell Lung Cancer

PURPOSE

For inoperable stage I (T1-T2N0) small cell lung cancer (SCLC), national guidelines recommend chemotherapy with or without conventionally fractionated radiation therapy. The present multi-institutional cohort study investigated the role of stereotactic ablative radiation therapy (SABR) for this population.

METHODS AND MATERIALS

The clinical and treatment characteristics, toxicities, outcomes, and patterns of failure were assessed in patients with histologically confirmed stage T1-T2N0M0 SCLC. Kaplan-Meier analysis was used to evaluate the survival outcomes. Univariate and multivariate analyses identified predictors of outcomes.

RESULTS

From 24 institutions, 76 lesions were treated in 74 patients (median follow-up 18 months). The median age and tumor size was 72 years and 2.5 cm, respectively. Chemotherapy and prophylactic cranial irradiation were delivered in 56% and 23% of cases, respectively. The median SABR dose and fractionation was 50 Gy and 5 fractions. The 1- and 3-year local control rate was 97.4% and 96.1%, respectively. The median disease-free survival (DFS) duration was 49.7 months. The DFS rate was 58.3% and 53.2% at 1 and 3 years, respectively. The median, 1-year, and 3-year disease-specific survival was 52.3 months, 84.5%, and 64.4%, respectively. The median, 1-year, and 3-year overall survival (OS) was 17.8 months, 69.9%, and 34.0% respectively. Patients receiving chemotherapy experienced an increased median DFS (61.3 vs 9.0 months; P=.02) and OS (31.4 vs 14.3 months; P=.02). The receipt of chemotherapy independently predicted better outcomes for DFS/OS on multivariate analysis (P=.01). Toxicities were uncommon; 5.2% experienced grade ≥2 pneumonitis. Post-treatment failure was most commonly distant (45.8% of recurrence), followed by nodal (25.0%) and "elsewhere lung" (20.8%). The median time to each was 5 to 7 months.

CONCLUSIONS

From the findings of the largest report of SABR for stage T1-T2N0 SCLC to date, SABR (≥50 Gy) with chemotherapy should be considered a standard option.

Prophylactic cranial irradiation after definitive chemoradiotherapy for limited-stage small cell lung cancer: Do all patients benefit?

PURPOSE

Prophylactic cranial irradiation (PCI) can improve overall survival (OS) and suppress brain metastases (BM) in patients with limited-stage small cell lung cancer (LS-SCLC) after complete response to primary therapy. However, PCI can be toxic. We sought to identify characteristics of patients who may not benefit from PCI.

METHODS

We identified 658 patients who received chemoradiotherapy at MD Anderson in 1986-2012; 364 received PCI and 294 did not. Median follow-up time was 21.2months (range 1.2-240.8months). Cox proportional hazards regression, competing-risk regression, and Kaplan-Meier analyses were used to identify factors influencing OS and BM.

RESULTS

PCI reduced risks of death [HR 0.73, 95% CI 0.61-0.88, P=0.001] and BM [HR 0.54, 95% CI 0.39-0.76, P<0.001]. Having tumors ⩾5cm increased the risk of BM [HR 1.77, 95% CI 1.22-2.55, P=0.002] but not death [HR 1.16, 95% CI 0.96-1.40, P=0.114]. Among patients ⩾70years with ⩾5-cm tumors, PCI did not improve OS [2-year rates 39.4% vs 40.9%, P=0.739].

CONCLUSIONS

PCI remains standard therapy after complete response to chemoradiotherapy for LS-SCLC. However, older patients may be at risk from comorbidity or extracranial disease. Further work is warranted to identify patients who may not benefit from PCI.

A multi-institutional analysis of peritransplantation radiotherapy in patients with relapsed/refractory Hodgkin lymphoma undergoing autologous stem cell transplantation

BACKGROUND

No consensus exists regarding the use of radiotherapy (RT) in conjunction with high-dose chemotherapy and autologous stem cell transplantation (HDC/ASCT) for patients with relapsed/refractory classical Hodgkin lymphoma (HL). The objectives of the current study were to characterize practice patterns and assess the efficacy and toxicity of RT at 2 major transplantation centers.

METHODS

Eligible patients underwent HDC/ASCT from 2006 through 2015 using the combination of either carmustine (BCNU), etoposide, cytarabine, and melphalan (BEAM) or cyclophosphamide, BCNU, and etoposide (CBV).

RESULTS

For the cohort of 189 patients, the 4-year overall survival rate was 80%, the progression-free survival rate was 67%, and the local control (LC) rate was 68%. RT was used within 4 months of ASCT for 22 patients (12%) and was given more often for disease that was early stage, primary refractory, or [¹⁸ F]fluorodeoxyglucose (FDG)-avid at the time of HDC/ASCT. Disease recurrence occurring after HDC/ASCT was associated with primary refractory disease and FDG-avidity at the time of HDC/ASCT. RT was not found to be associated with LC, progression-free survival, or overall survival on univariate analysis. In a model incorporating primary refractory HL and FDG-avid disease at the time of HDC/ASCT, RT was found to be associated with a decreased risk of local disease recurrence (hazard ratio, 0.3; P = .02). In patients with primary refractory HL and/or FDG-avid disease at the time of HDC/ASCT, the 4-year LC rate was 81% with RT versus 49% without RT (P = .03). There was one case of Common Terminology Criteria for Adverse Events grade ≥ 3 RT-related toxicity (acute grade 3 pancytopenia).

CONCLUSIONS

In patients undergoing ASCT for relapsed/refractory HL, peritransplantation RT was used more often for disease that was early stage, primary refractory, or FDG-avid after salvage conventional-dose chemotherapy. RT was associated with improved LC of high-risk localized disease and was well tolerated with modern techniques. Cancer 2017;123:1363-1371. © 2016 American Cancer Society.

Diffusion-Weighted Magnetic Resonance Imaging as a Predictor of Outcome in Cervical Cancer After Chemoradiation

PURPOSE

To determine whether apparent diffusion coefficient (ADC) value is predictive of survival after definitive chemoradiation for cervical cancer independent of established imaging and clinical prognostic factors.

METHODS AND MATERIALS

Between 2011 and 2013, the pretreatment MRI scans for 69 patients treated with definitive chemoradiation for newly diagnosed cervical cancer were retrieved. Scans were acquired with a 1.5-T magnetic resonance scanner, including diffusion-weighted imaging sequences. Mean ADC value was measured within a region of interest in the primary cervical cancer on the baseline MRI scan. Baseline tumor maximum standardized uptake value on positron emission tomography/computed tomography was determined by the reading radiologist. Treatment included external beam radiation therapy to the pelvis followed by brachytherapy in 97%, and with concurrent weekly cisplatin in 99% of patients. Univariate and multivariate analyses were done to investigate the association of clinical and imaging variables with disease control and survival endpoints using a Cox proportional hazard test.

RESULTS

Median follow-up was 16.7 months (range, 3.1-44.2 months). The 1-year overall survival, locoregional recurrence-free survival, and disease-free survival rates were 91%, 86%, and 74%, respectively. The median ADC value was 0.941 × 10^-3 mm²/s (range, 0.256-1.508 × 10^-3 mm²/s). The median standardized uptake value in the primary tumor was 15 (range, 6.2-43.4). In multivariate analysis, higher ADC value (hazard ratio [HR] 0.36, 95% confidence interval [CI] 0.15-0.85, P=.02), higher stage (HR 2.4, 95% CI 1.1-5.5, P=.033), and nonsquamous histology (HR 0.23, 95% CI 0.07-0.82, P=.024) were independent predictors of disease-free survival.

CONCLUSIONS

The mean ADC value of the primary tumor on pretreatment MRI was the only imaging feature that was an independent predictor of disease-free survival in cervical cancer patients treated with chemoradiation. Further validation will be needed to determine whether ADC values may prove useful in identifying cervical patients at high risk of recurrence.

Outcomes of Post Mastectomy Radiation Therapy in Patients Receiving Axillary Lymph Node Dissection After Positive Sentinel Lymph Node Biopsy

PURPOSE

We sought to determine the rate of postmastectomy radiation therapy (PMRT) among women treated with axillary lymph node dissection (ALND) after positive sentinel lymph node (SLN) biopsy results and to establish the effect of negative ALND results and PMRT on locoregional recurrence (LRR) and overall survival (OS).

METHODS AND MATERIALS

All patients were treated with mastectomy and ALND after positive SLN biopsy results. All patients had clinical N0 or NX disease at the time of mastectomy and received no neoadjuvant therapy. The presence of lymphovascular space invasion, presence of multifocality, number of positive SLNs and non-SLNs, clinical and pathologic stage, extranodal extension, age, and use of PMRT were evaluated for significance regarding the rates of OS and LRR.

RESULTS

A total of 345 patients were analyzed. ALND after positive SLN biopsy results was negative in 235 patients (68.1%), and a total of 112 patients (32.5%) received radiation therapy. On multivariate analysis, only pathologic stage III predicted for lower OS (hazard ratio, 3.32; P<.001). The rate of 10-year freedom from LRR was 87.9% and 95.3% in patients with positive ALND results and patients with negative ALND results, respectively. In patients with negative ALND results with ≥3 positive SLNs, the rate of freedom from LRR was 74.7% compared with 96.7% in those with <3 positive SLNs (P=.009). In patients with negative ALND results, ≥3 positive SLNs predicted for an increase in LRR on multivariate analysis (hazard ratio, 10.10; P=.034).

CONCLUSIONS

A low proportion of cT1-2, N0 patients with positive SLNs who undergo mastectomy receive PMRT after ALND. Even in this low-risk cohort, patients with ≥3 positive SLNs and negative ALND results are at increased risk of LRR and may benefit from PMRT.