Outcomes of Bimodality and Trimodality Therapy in Patients with Stage III Non-small Cell Lung Cancer...
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Results: Median age at time of treatment was 61.5 years (Range: 40-82 years). Median follow-up was 1.6 months (Range: 0-28 months). All patients have died at time of review. Using CTCAE version 4.0, there were no grade 3 or 4 toxicities. One patient developed grade 2 radiation pneumonitis, 8 patients developed acute grade 2 esophagitis, and 3 patients developed grade 1 radiation dermatitis. Among the 12 patients who had longer than 1 month follow-up, 6 patients had no evidence of local progression, and the median local control of the other 5 who did recur was 3.1 months. Nine out of the 14 symptomatic patients had successful palliation within a month after completion of treatment. Median overall survival was 2.8 months (Range: 1-28 months), and median disease free survival was 2.6 months (Range: 1-28 months). One year overall survival was 20%, and 1 year disease free survival was 10%. Patients receiving greater than or equal to EQD 2 40Gy to the tumor for salvage had statistically significant higher overall median survival (7.8 months vs. 1.2 months p = 0.004). Conclusions: The use of neutron only or mixed neutron and photon RT for salvage therapy for NSCLC is very well tolerated with no events of grade 3 or higher toxicities, successful palliation in the majority of symptomatic patients, and local control in half of the patients treated. Author Disclosure: G.G. Chen, None; L. Kollar, None; P. Paximadis, None; M. Joiner, None; J. Burmeister, None; S.M. Gadgeel, None; A.J. Wozniak, None; F. Baciewicz, None; A. Konski, None. 2673 Outcomes of Bimodality and Trimodality Therapy in Patients with Stage III Non-small Cell Lung Cancer (NSCLC) A. J. Hope, L. E. Coate, C. Massey, A. Sacher, K. Barrett, S. Keshavjee, G. Darling, N. B. Leighl, A. Bezjak, F. A. Shepherd Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada Purpose/Objective(s): To determine outcomes following bimodality or trimodality treatment in patients with stage III NSCLC treated in a single institution. Materials/Methods: Following ethics approval, a retrospective review identified 1302 stage III NSCLC patients treated at our institution from 1997-2007. Patients with micrometastatic N2 disease detected at surgery, malignant pleural effusion, or palliative treatment intent were excluded, leaving 366 patients treated with bimodality (.40 Gy radiation + chemotherapy, n = 212) or trimodality therapy (n = 154). Demographics, treatment, toxicity, and survival were compared using log-rank and univariate statistical tests. Survival analysis was performed using the Kaplan-Meier method. Results: Of the 366 patients, 204 were IIIA (T1-2N2: 166, T3N1-2: 38) and 162 IIIB (T4N0-1: 66, T4N2: 34, T1-4N3: 62). Trimodality treatment was less commonly used in patients with IIIB (32%) vs. IIIA (50%, p \0.01), older patients (p \0.01), with more comorbidities (p \ 0.01), or weight loss (p = 0.01). Disease burden was the most common documented reason (27%) for non-surgical treatment in patients in the bimodality group. Without accounting for these selection factors, there was a difference in 5y survival favoring trimodality treatment (35% vs. 16%, HR = 0.65, p \ 0.01). This difference was also seen in the N2 subgroup (30% vs. 15%, HR .72, p = 0.04). The difference in survival in the T4N0-1 subgroup between trimodality and bimodality was not significant (42% vs. 22%, HR .77, p = 0.4). Patients receiving trimodality therapy had a lower risk of 5y loco-regional failure: all patients: 32% vs. 53%, HR = 0.5, p \ 0.01; IIIA: 34% vs. 49%, HR .56, p = 0.03; IIIB: 27% vs. 57%, HR 0.45, p \ 0.01. The trimodality group had a higher risk of treatment related death (6% vs. 2%, p = 0.02). Conclusions: In our center, well-selected patients with stage III NSCLC treated with trimodality therapy appear to have improved rates of loco-regional recurrence and overall survival, despite an increased risk of treatment related death. Author Disclosure: A.J. Hope, None; L.E. Coate, None; C. Massey, None; A. Sacher, None; K. Barrett, None; S. Keshavjee, None; G. Darling, None; N.B. Leighl, None; A. Bezjak, None; F.A. Shepherd, None. 2674 The Effect of Increasing Experience with Intensity Modulated Radiation Therapy for Resected Malignant Pleural Mesothelioma P. R. Patel 1 , S. Yoo 1 , L. Marks 2 , E. Miles 3 , T. A. D’Amico 4 , D. H. Harpole 4 , C. Kelsey 1 1 Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 2 Department of Radiation Oncology, University of North Carolina, Chapel Hill, NC, 3 Department of Radiation Oncology, NMC Portsmouth, Portsmouth, VA, 4 Department of Surgery, Duke University Medical Center, Durham, NC Purpose/Objective(s): The risk of local recurrence after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) is high. Intensity modulated radiation therapy (IMRT) is often administered to decrease this risk, though high rates of pulmonary toxicity have been reported. We herein assess the impact of evolving experience on dosimetric parameters and report outcomes and toxicity after treatment. Materials/Methods: The records of all patients who received hemithoracic IMRT following EPP at Duke University Medical Center between 2005 and 2010 were reviewed. Patients were typically treated with 9-11 beams using 6 and 15 MV photons. Gantry angles, collimator rotations, and beam apertures were manually fixed based on beam’s eye-view to avoid the contralateral lung while optimizing target coverage. Target volumes included the entire ipsilateral hemithorax, chest wall incisions, involved nodal stations, and a boost to close/positive surgical margins if applicable. Toxicity was graded using the CTC version 4.0. Target coverage and contralateral lung irradiation were evaluated over time using linear regression. Local control, distant control, and overall survival were estimated using the Kaplan-Meier method. Results: Thirty patients received IMRT following EPP; 20 also received systemic chemotherapy. Median follow-up was 14 months. The dose prescribed to the entire ipsilateral hemithorax was 40-50.4 Gy (median 45 Gy) with a boost of 8-15 Gy in 9 patients. The average percent of the planning target volume receiving at least 98% and less than 90% of the prescription dose was 86.3% and 3.9%, respectively. Increasing experience planning MPM cases was associated with improved coverage of planning target volumes (p = 0.02). Similarly, mean lung dose (p \0.01) and lung V5 (p \0.01) values decreased with increasing experience. Lung toxicity developed after IMRT in 4 (13%) patients at a median of 2.2 months after RT (one grade 2, two grade 3, and one Proceedings of the 52nd Annual ASTRO Meeting S505
Transcript of Outcomes of Bimodality and Trimodality Therapy in Patients with Stage III Non-small Cell Lung Cancer...
Proceedings of the 52nd Annual ASTRO Meeting S505
Results: Median age at time of treatment was 61.5 years (Range: 40-82 years). Median follow-up was 1.6 months (Range: 0-28months). All patients have died at time of review. Using CTCAE version 4.0, there were no grade 3 or 4 toxicities. One patientdeveloped grade 2 radiation pneumonitis, 8 patients developed acute grade 2 esophagitis, and 3 patients developed grade 1 radiationdermatitis. Among the 12 patients who had longer than 1 month follow-up, 6 patients had no evidence of local progression, and themedian local control of the other 5 who did recur was 3.1 months. Nine out of the 14 symptomatic patients had successful palliationwithin a month after completion of treatment. Median overall survival was 2.8 months (Range: 1-28 months), and median diseasefree survival was 2.6 months (Range: 1-28 months). One year overall survival was 20%, and 1 year disease free survival was 10%.Patients receiving greater than or equal to EQD2 40Gy to the tumor for salvage had statistically significant higher overall mediansurvival (7.8 months vs. 1.2 months p = 0.004).
Conclusions: The use of neutron only or mixed neutron and photon RT for salvage therapy for NSCLC is very well tolerated withno events of grade 3 or higher toxicities, successful palliation in the majority of symptomatic patients, and local control in half of thepatients treated.
Author Disclosure: G.G. Chen, None; L. Kollar, None; P. Paximadis, None; M. Joiner, None; J. Burmeister, None; S.M. Gadgeel,None; A.J. Wozniak, None; F. Baciewicz, None; A. Konski, None.
2673 Outcomes of Bimodality and Trimodality Therapy in Patients with Stage III Non-small Cell Lung
Cancer (NSCLC)A. J. Hope, L. E. Coate, C. Massey, A. Sacher, K. Barrett, S. Keshavjee, G. Darling, N. B. Leighl, A. Bezjak, F. A. Shepherd
Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada
Purpose/Objective(s): To determine outcomes following bimodality or trimodality treatment in patients with stage III NSCLCtreated in a single institution.
Materials/Methods: Following ethics approval, a retrospective review identified 1302 stage III NSCLC patients treated at ourinstitution from 1997-2007. Patients with micrometastatic N2 disease detected at surgery, malignant pleural effusion, or palliativetreatment intent were excluded, leaving 366 patients treated with bimodality (.40 Gy radiation + chemotherapy, n = 212) ortrimodality therapy (n = 154). Demographics, treatment, toxicity, and survival were compared using log-rank and univariatestatistical tests. Survival analysis was performed using the Kaplan-Meier method.
Results: Of the 366 patients, 204 were IIIA (T1-2N2: 166, T3N1-2: 38) and 162 IIIB (T4N0-1: 66, T4N2: 34, T1-4N3: 62).Trimodality treatment was less commonly used in patients with IIIB (32%) vs. IIIA (50%, p\0.01), older patients (p\0.01),with more comorbidities (p \ 0.01), or weight loss (p = 0.01). Disease burden was the most common documented reason(27%) for non-surgical treatment in patients in the bimodality group. Without accounting for these selection factors, therewas a difference in 5y survival favoring trimodality treatment (35% vs. 16%, HR = 0.65, p \ 0.01). This difference wasalso seen in the N2 subgroup (30% vs. 15%, HR .72, p = 0.04). The difference in survival in the T4N0-1 subgroup betweentrimodality and bimodality was not significant (42% vs. 22%, HR .77, p = 0.4). Patients receiving trimodality therapy had alower risk of 5y loco-regional failure: all patients: 32% vs. 53%, HR = 0.5, p \ 0.01; IIIA: 34% vs. 49%, HR .56, p = 0.03;IIIB: 27% vs. 57%, HR 0.45, p \ 0.01. The trimodality group had a higher risk of treatment related death (6% vs. 2%,p = 0.02).
Conclusions: In our center, well-selected patients with stage III NSCLC treated with trimodality therapy appear to have improvedrates of loco-regional recurrence and overall survival, despite an increased risk of treatment related death.
Author Disclosure: A.J. Hope, None; L.E. Coate, None; C. Massey, None; A. Sacher, None; K. Barrett, None; S. Keshavjee, None;G. Darling, None; N.B. Leighl, None; A. Bezjak, None; F.A. Shepherd, None.
2674 The Effect of Increasing Experience with Intensity Modulated Radiation Therapy for Resected Malignant
Pleural MesotheliomaP. R. Patel1, S. Yoo1, L. Marks2, E. Miles3, T. A. D’Amico4, D. H. Harpole4, C. Kelsey1
1Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 2Department of Radiation Oncology,University of North Carolina, Chapel Hill, NC, 3Department of Radiation Oncology, NMC Portsmouth, Portsmouth, VA,4Department of Surgery, Duke University Medical Center, Durham, NC
Purpose/Objective(s): The risk of local recurrence after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma(MPM) is high. Intensity modulated radiation therapy (IMRT) is often administered to decrease this risk, though high rates ofpulmonary toxicity have been reported. We herein assess the impact of evolving experience on dosimetric parameters and reportoutcomes and toxicity after treatment.
Materials/Methods: The records of all patients who received hemithoracic IMRT following EPP at Duke University MedicalCenter between 2005 and 2010 were reviewed. Patients were typically treated with 9-11 beams using 6 and 15 MV photons. Gantryangles, collimator rotations, and beam apertures were manually fixed based on beam’s eye-view to avoid the contralateral lungwhile optimizing target coverage. Target volumes included the entire ipsilateral hemithorax, chest wall incisions, involved nodalstations, and a boost to close/positive surgical margins if applicable. Toxicity was graded using the CTC version 4.0. Targetcoverage and contralateral lung irradiation were evaluated over time using linear regression. Local control, distant control, andoverall survival were estimated using the Kaplan-Meier method.
Results: Thirty patients received IMRT following EPP; 20 also received systemic chemotherapy. Median follow-up was 14months. The dose prescribed to the entire ipsilateral hemithorax was 40-50.4 Gy (median 45 Gy) with a boost of 8-15 Gy in 9patients. The average percent of the planning target volume receiving at least 98% and less than 90% of the prescription dosewas 86.3% and 3.9%, respectively. Increasing experience planning MPM cases was associated with improved coverage of planningtarget volumes (p = 0.02). Similarly, mean lung dose (p\0.01) and lung V5 (p\0.01) values decreased with increasing experience.Lung toxicity developed after IMRT in 4 (13%) patients at a median of 2.2 months after RT (one grade 2, two grade 3, and one
