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Acute Skin Toxicity Using High-Dose-Rate Electronic Brachytherapy for Nonmelanoma Skin Cancer
S754
International Journal of Radiation Oncology Biology Physics
Reus, Reus, Spain, 2Radiation Oncology Department, Institut Oncolo`gic del Valle`s (IOV), Barcelona, Spain, 3Radiation Oncology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
bone, skin, skin corridor, and PTV were compared. D25, the dose received by 25% of the target volume, inhomogeneity as per Wu et al.[(D2-D98)/ (prescription dose)*100] and R50 values were also compared. Results: The average PTV volume was 1701.25 mL (range, 813.5-3190.0). In all cases, both the clinically delivered LINAC plan and the modulated 60 Co plan covered 95% of the PTV. The mean R50 values were 2.07 and 2.42 for the LINAC and 60Co plans, respectively, while the mean PTV inhomogeneity values were 9.78 and 13.51. Dosimetric parameters for the skin corridor, in-field long bone (either the femur [n Z 3] or the tibiafibula complex [n Z 1]), and skin are shown in Table 1. Conclusions: An MRI-guided radiation therapy system utilizing modulated 60Co beams can deliver IMRT for preoperative STS with comparable dosimetry to clinically delivered LINAC-based IMRT. Even greater improvements can be achieved as MRI-guided radiation therapy allows for smaller planning margins. Based on this analysis, a clinical trial is being initiated to evaluate treatment outcomes and toxicities using modulated 60 Co IMRT. Author Disclosure: A.U. Kishan: None. M. Cao: None. D.A. Low: K. Advisory Board; Feasibility of MRI-guided Tri-Cobalt-60 IMRT for Preoperative Radiotherapy of Soft Tissue Sarcomas. P.A. Kupelian: K. Advisory Board; Scientific Advisory Board for ViewRay Inc. M.L. Steinberg: None. M.R. Kamrava: None.
Purpose/Objective(s): Non-melanoma skin cancer (NMSC) is the most frequently occurring cancer in humans. Different options currently exist to treat NMSC, such as topical treatments, surgery and radiation. The aim of this study was to analyze the outcomes, toxicity and cosmesis after patients (pts) with NMSC were treated by hypofractionated high dose rate brachytherapy (HHDR-B). Materials/Methods: 141 NMSC lesions were treated by HHDR-B. Hypofractionated treatment of 3 Gy was delivered three times a week, up to a total dose of between 45 and 54 Gy. A fixed applicator was used on 106 lesions, whereas a customized mould was used on 35 lesions. Results: With a median follow up of 24 months, local control at 2 years was 92%. Complete regression was achieved in the 96.45% of the lesions. Eleven treatment failures were observed: two partial responses, three with persistent disease, and six marginal field recurrences. Fifty-five pts (40%) had grade 2 or higher acute skin toxicity. Five patients (4.25%) had grade 4 acute skin toxicity. The cosmesis outcomes were excellent or good in 82% of pts and fair in 10% of pts. Conclusions: HHDR-B is an effective and well-tolerated treatment for non-melanoma skin cancer. Author Disclosure: M. Arenas: None. M. Arguı´s: None. L. Dı´ez-Presa: None. I. Henrı´quez: None. M. Murcia-Mejı´a: None. M. Gasco´n: None. D. Go´mez: None. A. Lafuerza: None. E. Mur: None. S. Sabater: None.
3381 Feasibility of MRI-Guided Tri-Cobalt-60 IMRT for Preoperative Radiation therapy of Soft-Tissue Sarcomas A.U. Kishan, M. Cao, D.A. Low, P.A. Kupelian, M.L. Steinberg, and M.R. Kamrava; University of California, Los Angeles, Los Angeles, CA Purpose/Objective(s): Contouring of extremity soft tissue sarcomas are best accomplished using MRI guidance. Challenges exist with accurately fusing MRI with CT simulation images as the patient is often in different positions. The ability to simulate, plan, and treat using MRI alone presents an opportunity to improve treatment for this group of patients both in terms of target definition and minimizing daily treatment variations. We hypothesized that a modulated MRI-guided cobalt 60 (60Co) planning system could create IMRT plans that approximate linear accelerator (LINAC) based plans. Materials/Methods: The primary study population consisted of four patients with lower extremity sarcoma who were treated with pre-operative IMRT to 50 Gy in 25 fractions in our department within the last year. Target volumes were contoured as per the recent consensus guidelines from Haas et al. CTV to PTV expansion was 5 mm. A commerciallyavailable MRI-guided tri-60Co planning system was used to generate IMRT plans based on the same dosing schema and contours. A skin corridor was defined as a volume 180 degrees from the center of the PTV, encompassing 30-40% of the circumference of the extremity. Doses to the
Scientific Abstract 3381; Table Selected Average Dosimetric Parameters for LINAC and Modulated Cobalt-60 IMRT Plans (n Z 4)
Skin Corridor D25 (Gy) Mean Dose (Gy) Max Dose (Gy) Long Bone D25 (Gy) Mean Dose (Gy) Max Dose (Gy) V40 (%) Skin D1cc (Gy)
LINAC Plans
Modulated Cobalt-60 Plans
19.0 13.6 40.7
23.2 17.4 36.9
36.6 25.5 48.6 31.5
35.1 25.0 53.6 34.1
52.3
56.5
3382 Acute Skin Toxicity Using High-Dose-Rate Electronic Brachytherapy for Nonmelanoma Skin Cancer M.K. Cheung, Y. Kim, S.E. Sckolnik, J.L. Grow, B.G. Slane, J.D. Gordon, and B. Stea; University of Arizona, Tucson, Arizona, AZ Purpose/Objective(s): High Dose Rate Electronic Brachytherapy (HDREBT) is an alternate treatment modality for patients with non-melanomatous skin cancers who are not candidates for surgery. This study seeks to identify and characterize factors associated with treatment toxicity using this radiation modality. Materials/Methods: Retrospective review of 33 patients with 50 lesions treated at our institution from April 2011-May 2013 was performed with IRB approval. All lesions were pathologically confirmed malignant basal (56%) or squamous (44%) cell carcinoma. Median age was 76 years (range: 43-92) and median tumor size was 1cm (range: 0.2cm-3cm). A HDR-EBT system delivered a median BED of 60Gy (a/b Z 10; range: BED 6.3-69.6Gy/2-29fx) to a depth of 0.1-0.5cm using an appropriate sized applicator (range: 1-5cm diameter). Treatment toxicity was evaluated using the RTOG/EORTC Acute/Late Radiation Morbidity Scoring Criteria. Results: Local control is 100% with a median follow-up of 3.6 months. Acute grade 3 moist desquamation developed in 9 of the treated lesions (18%). Acute grade 4 ulceration manifested in 3 lesions in the lower extremity (6%) and 1 lesion on the upper lip (2%) and occurred a median of 23 days from the start of treatment. Table 1 compares the acute toxicities between lower extremity vs head and neck (HN) sites (ear, eyelid, nose, and scalp). The proportion of lesions developing acute grade 2-3 toxicity was similar between the two groups (47.1% vs 48.5%), but a greater proportion of acute grade 4 toxicity developed in lower extremity lesions (17.6% vs 3.0%). There was also a greater proportion of acute grade 4 toxicity in lesions treated with fraction size 500cGy vs 70, p Z 0.10), treatment depth (2mm vs >2mm, p Z 0.22), number of treatment fractions (21 days, p Z 010). One patient developed late grade 4 toxicity with a non-healing ulcer in the lower extremity 3.4 months after completion of treatment.
Scientific Abstract 3382; Table
Toxicity Grade Grade Grade Grade Grade
1 2 3 4
Acute Toxicity by Lesion Location
Lower Extremity Lesions (n Z 17)
Head and Neck Lesions (n Z 33)
6 (35.3%) 8 (47.1%) 0 (0.0%) 3 (17.6%)
16 (48.5%) 7 (21.2%) 9 (27.3%) 1 (3.0%)
Fisher Exact Test P Z .009
Volume 90 Number 1S Supplement 2014 Conclusions: Early toxicity outcomes of HDR-EBT for non-melanomatous skin cancers are encouraging with <10% acute grade 4 toxicities. However, lower extremity lesions should be treated with caution as suboptimal vascular perfusion at these sites may impede desquamated skin from healing, resulting in greater risk for ulceration. Author Disclosure: M.K. Cheung: None. Y. Kim: None. S.E. Sckolnik: None. J.L. Grow: None. B.G. Slane: None. J.D. Gordon: None. B. Stea: None.
3383 Effects of Adjuvant Radiation Therapy in Patients With Synovial Sarcoma S. Song,1 S. Kim,1 J. Park,1 H. Kim,2 and I. Kim2; 1Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea, Republic of Korea, 2Seoul National University Hospital, Seoul, Korea, Republic of Korea Purpose/Objective(s): To analyze treatment outcomes and evaluate effects of adjuvant radiation therapy (RT) in patients with synovial sarcoma. Materials/Methods: Medical records of 103 patients treated with definitive surgery with/without RT for synovial sarcoma from August 1982 to July 2013 were retrospectively reviewed. The median age of patients was 33 years (range, 5-72). Tumor locations were extremities in 79 (77%) patients. Seventy-five (73%) patients received adjuvant RT and 26 (25%) did not. The median dose of adjuvant RT was 61.2 Gy (range, 45-66.6). Results: Median follow-up duration was 6.5 years (range, 0.4-31.0). The 5- and 10-year overall survival (OS) rates were 77 % and 65%, respectively. The progression-free survival (PFS) rates at 5 and 10 years were 52% and 43%, respectively. The most common site of initial failure was lung (24 patients) followed by local recurrence (14 patients). Five-year local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) rates were 80% and 63%, respectively. On multivariate analysis, mitosis count lower than 10 per 10 high-power fields (HPF) was significant predictors of better OS, PFS, LRFS and DMFS rates (P Z 0.004, <0.001, 0.025 and <0.001, respectively). Use of adjuvant RT was additional prognostic factor for better PFS and LRFS (P Z 0.006 and 0.028, respectively). For DMFS, positive/uncheckable resection margin was also associated with poor prognosis (P Z 0.011). There was no significant difference of LRFS between higher and lower RT dose groups (less than 63 Gy group, 89% vs 63 Gy or more group, 88%, P Z 0.772). Conclusions: Lung and primary site were frequent sites of failure in patients treated with definitive surgery for synovial sarcoma. Adjuvant RT improved LRFS and PFS rates and frequent mitotic figure (Ten or more mitoses per 10 HPF) was a worse prognostic factor for these patients. Author Disclosure: S. Song: None. S. Kim: None. J. Park: None. H. Kim: None. I. Kim: None.
3384 HDR Brachytherapy for Resected Retroperitoneal Sarcoma in the Primary and Recurrent Setting A. Kumar,1 J.J. Juliano,1 R.M. Walsh,2 S. Chalikonda,2 and K. Stephans2; 1 Cleveland Clinic Foundation, Cleveland, OH, 2Cleveland Clinic, Cleveland, OH Purpose/Objective(s): As surgery alone for retroperitoneal (RP) sarcoma has a local recurrence (LR) as high as 50-80%, there is theoretical rationale but mixed clinical evidence to support the addition of radiation therapy to reduce LR. Peri-operative brachytherapy (POB) has the advantage of dose escalation using targeted radiation via catheters along with bowel displacement to reduce toxicity. We present outcomes of RP sarcoma patients treated with surgery and HDR brachytherapy alone. Materials/Methods: 11 patients diagnosed with RP sarcoma had tumor resection and Harrison-Anderson-Mick (HAM) applicator placed intraoperatively. These patients were treated with Ir-192 HDR brachytherapy over 1-3 days and subsequent removal of HAM applicator. Outcomes of all 11 patients were analyzed to assess LR. Histology was based on FNCLCC
Poster Viewing Abstracts S755 grading (1-3). A patterns of failure analysis was also done on patients with LR. Results: 6 patients were treated at primary resection, while 5 were treated for recurrent disease. Only 1 (9%) patient had a negative margin and 3 patients had no margins reported but had tumor encased in a pseudocapsule. Total HDR dose was 14 Gy / 1 fx (1), 20 Gy / 2 fx (1), 18 Gy / 2 fx (1), 21 Gy / 3 fx (5), 18 Gy / 3 fx (1), or 28 Gy / 4 fx (2) to 1 cm with prescription biological equivalent dose (BED) range: 28.8 - 47.6. Median follow up was 25 months (2-56). There were no significant toxicities reported related to POB. All five patients treated for recurrent disease developed LR, while 3 (50%) patients treated at primary resection developed LR. Median time to LR was 18 mos (27 mos primary resection, 17 mos recurrence). All 3 patients without LR had positive margins; 2 had grade 1 and 1 had grade 2 disease. There was no clear correlation between LR and dose, fractionation, or calculated BED. The patient with negative margins had LR in spite of POB. Of the 8 patients with LR, 1 (13%) LR was in the HDR field, 3 (36%) were adjacent to where the HAM applicator was placed and outside the HDR field, 2 (25%) were between loops of bowel, 1 LR was large and within both the HAM field and an adjacent site, and 1 LR had caused malignant ascites but it was difficult to determine the location of a solid component. Six (75%) LRs were outside the HDR field but in adjacent sites and would have likely been encompassed in a standard EBRT field. Conclusions: Local recurrence after POB alone is high for both primary and recurrent RP sarcomas. Based on patterns of failure analysis, we would recommend the addition of supplemental EBRT particularly for grade 3 histology and recurrent disease. Author Disclosure: A. Kumar: None. J.J. Juliano: None. R.M. Walsh: None. S. Chalikonda: None. K. Stephans: None.
3385 Prognostic Factors in Alveolar Soft-Part Sarcoma: A SEER Analysis H. Wang,1,2 A. Jacobson,1 D. Harmon,1,3 J. Michaelson,1,3 T.F. DeLaney,1,3 and Y. Chen1,3; 1Massachusetts General Hospital, Boston, MA, 2Peking Union Medical College, Beijing, China, 3Harvard Medical School, Boston, MA Purpose/Objective(s): Alveolar soft-part sarcomas (ASPS) are extremely rare soft tissue sarcomas. We analyzed the outcomes of ASPS in the Surveillance, Epidemiology, and End Result (SEER) Registry. Materials/Methods: The SEER Registry was queried for patients diagnosed of ASPS from 1973 to 2010. Kaplan-Meier analysis and Cox proportional hazards regression were used to analyze ASPS overall survival, disease specific survival, and prognostic factors. Results: A total number of 216 patients with ASPS were identified, with 123 (56.9%) female and 93 (43.1%) male. The median age was 27, with 80.6% < 35 years old. Clinically 107 (49.5%) patients presented with local-regional disease, and 91 (42.1%) with distant disease. Extremities are the most common disease site, accounting for 133 cases (62.0%). 43 (19.9%) cases were >10cm in size, 61 (28.2%) were 5-10 cm, and 49 (22.7%) were <5cm. Treatment included surgery only in 81 (37.5%) patients, radiation only in 24 (11.1%) patients, surgery + radiation in 82 (38.0%) patients and no treatment in 23 (10.7%) patients. Of the surgery + radiation group, radiation was given post-operatively for 66 cases, preoperatively for 11 cases, and other for 5 cases. The median follow-up was 49 months. The 2-, 5-, 10- year overall survival rates were 82%, 57%, and 38%, and the 2-, 5-, and 10-year DSS rates were 83%, 60%, and 40%, respectively. A Cox proportional hazards model identified older age [hazard ratio (HR) Z 1.03 per year, P Z 0.00077], male sex (HR Z 1.63, P Z 0.024), large tumor size of >10cm (HR Z 2.76, P Z 0.022), distant metastasis at diagnosis (HR Z 3.23, P Z 0.00004), trunk as primary tumor site (HR Z 2.06, P Z 0.00349), no treatment group (HR Z 2.1, P Z 0.01861) and only radiation without surgery (HR Z 2.9, P Z 0.00232) as independent factors affecting OS and DSS. Finally, use of adjuvant radiation therapy with surgery was not seen as a predictor of improved OS and DSS (P Z 0.13 and P Z 0.28), respectively.
International Journal of Radiation Oncology Biology Physics
Reus, Reus, Spain, 2Radiation Oncology Department, Institut Oncolo`gic del Valle`s (IOV), Barcelona, Spain, 3Radiation Oncology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
bone, skin, skin corridor, and PTV were compared. D25, the dose received by 25% of the target volume, inhomogeneity as per Wu et al.[(D2-D98)/ (prescription dose)*100] and R50 values were also compared. Results: The average PTV volume was 1701.25 mL (range, 813.5-3190.0). In all cases, both the clinically delivered LINAC plan and the modulated 60 Co plan covered 95% of the PTV. The mean R50 values were 2.07 and 2.42 for the LINAC and 60Co plans, respectively, while the mean PTV inhomogeneity values were 9.78 and 13.51. Dosimetric parameters for the skin corridor, in-field long bone (either the femur [n Z 3] or the tibiafibula complex [n Z 1]), and skin are shown in Table 1. Conclusions: An MRI-guided radiation therapy system utilizing modulated 60Co beams can deliver IMRT for preoperative STS with comparable dosimetry to clinically delivered LINAC-based IMRT. Even greater improvements can be achieved as MRI-guided radiation therapy allows for smaller planning margins. Based on this analysis, a clinical trial is being initiated to evaluate treatment outcomes and toxicities using modulated 60 Co IMRT. Author Disclosure: A.U. Kishan: None. M. Cao: None. D.A. Low: K. Advisory Board; Feasibility of MRI-guided Tri-Cobalt-60 IMRT for Preoperative Radiotherapy of Soft Tissue Sarcomas. P.A. Kupelian: K. Advisory Board; Scientific Advisory Board for ViewRay Inc. M.L. Steinberg: None. M.R. Kamrava: None.
Purpose/Objective(s): Non-melanoma skin cancer (NMSC) is the most frequently occurring cancer in humans. Different options currently exist to treat NMSC, such as topical treatments, surgery and radiation. The aim of this study was to analyze the outcomes, toxicity and cosmesis after patients (pts) with NMSC were treated by hypofractionated high dose rate brachytherapy (HHDR-B). Materials/Methods: 141 NMSC lesions were treated by HHDR-B. Hypofractionated treatment of 3 Gy was delivered three times a week, up to a total dose of between 45 and 54 Gy. A fixed applicator was used on 106 lesions, whereas a customized mould was used on 35 lesions. Results: With a median follow up of 24 months, local control at 2 years was 92%. Complete regression was achieved in the 96.45% of the lesions. Eleven treatment failures were observed: two partial responses, three with persistent disease, and six marginal field recurrences. Fifty-five pts (40%) had grade 2 or higher acute skin toxicity. Five patients (4.25%) had grade 4 acute skin toxicity. The cosmesis outcomes were excellent or good in 82% of pts and fair in 10% of pts. Conclusions: HHDR-B is an effective and well-tolerated treatment for non-melanoma skin cancer. Author Disclosure: M. Arenas: None. M. Arguı´s: None. L. Dı´ez-Presa: None. I. Henrı´quez: None. M. Murcia-Mejı´a: None. M. Gasco´n: None. D. Go´mez: None. A. Lafuerza: None. E. Mur: None. S. Sabater: None.
3381 Feasibility of MRI-Guided Tri-Cobalt-60 IMRT for Preoperative Radiation therapy of Soft-Tissue Sarcomas A.U. Kishan, M. Cao, D.A. Low, P.A. Kupelian, M.L. Steinberg, and M.R. Kamrava; University of California, Los Angeles, Los Angeles, CA Purpose/Objective(s): Contouring of extremity soft tissue sarcomas are best accomplished using MRI guidance. Challenges exist with accurately fusing MRI with CT simulation images as the patient is often in different positions. The ability to simulate, plan, and treat using MRI alone presents an opportunity to improve treatment for this group of patients both in terms of target definition and minimizing daily treatment variations. We hypothesized that a modulated MRI-guided cobalt 60 (60Co) planning system could create IMRT plans that approximate linear accelerator (LINAC) based plans. Materials/Methods: The primary study population consisted of four patients with lower extremity sarcoma who were treated with pre-operative IMRT to 50 Gy in 25 fractions in our department within the last year. Target volumes were contoured as per the recent consensus guidelines from Haas et al. CTV to PTV expansion was 5 mm. A commerciallyavailable MRI-guided tri-60Co planning system was used to generate IMRT plans based on the same dosing schema and contours. A skin corridor was defined as a volume 180 degrees from the center of the PTV, encompassing 30-40% of the circumference of the extremity. Doses to the
Scientific Abstract 3381; Table Selected Average Dosimetric Parameters for LINAC and Modulated Cobalt-60 IMRT Plans (n Z 4)
Skin Corridor D25 (Gy) Mean Dose (Gy) Max Dose (Gy) Long Bone D25 (Gy) Mean Dose (Gy) Max Dose (Gy) V40 (%) Skin D1cc (Gy)
LINAC Plans
Modulated Cobalt-60 Plans
19.0 13.6 40.7
23.2 17.4 36.9
36.6 25.5 48.6 31.5
35.1 25.0 53.6 34.1
52.3
56.5
3382 Acute Skin Toxicity Using High-Dose-Rate Electronic Brachytherapy for Nonmelanoma Skin Cancer M.K. Cheung, Y. Kim, S.E. Sckolnik, J.L. Grow, B.G. Slane, J.D. Gordon, and B. Stea; University of Arizona, Tucson, Arizona, AZ Purpose/Objective(s): High Dose Rate Electronic Brachytherapy (HDREBT) is an alternate treatment modality for patients with non-melanomatous skin cancers who are not candidates for surgery. This study seeks to identify and characterize factors associated with treatment toxicity using this radiation modality. Materials/Methods: Retrospective review of 33 patients with 50 lesions treated at our institution from April 2011-May 2013 was performed with IRB approval. All lesions were pathologically confirmed malignant basal (56%) or squamous (44%) cell carcinoma. Median age was 76 years (range: 43-92) and median tumor size was 1cm (range: 0.2cm-3cm). A HDR-EBT system delivered a median BED of 60Gy (a/b Z 10; range: BED 6.3-69.6Gy/2-29fx) to a depth of 0.1-0.5cm using an appropriate sized applicator (range: 1-5cm diameter). Treatment toxicity was evaluated using the RTOG/EORTC Acute/Late Radiation Morbidity Scoring Criteria. Results: Local control is 100% with a median follow-up of 3.6 months. Acute grade 3 moist desquamation developed in 9 of the treated lesions (18%). Acute grade 4 ulceration manifested in 3 lesions in the lower extremity (6%) and 1 lesion on the upper lip (2%) and occurred a median of 23 days from the start of treatment. Table 1 compares the acute toxicities between lower extremity vs head and neck (HN) sites (ear, eyelid, nose, and scalp). The proportion of lesions developing acute grade 2-3 toxicity was similar between the two groups (47.1% vs 48.5%), but a greater proportion of acute grade 4 toxicity developed in lower extremity lesions (17.6% vs 3.0%). There was also a greater proportion of acute grade 4 toxicity in lesions treated with fraction size 500cGy vs 70, p Z 0.10), treatment depth (2mm vs >2mm, p Z 0.22), number of treatment fractions (21 days, p Z 010). One patient developed late grade 4 toxicity with a non-healing ulcer in the lower extremity 3.4 months after completion of treatment.
Scientific Abstract 3382; Table
Toxicity Grade Grade Grade Grade Grade
1 2 3 4
Acute Toxicity by Lesion Location
Lower Extremity Lesions (n Z 17)
Head and Neck Lesions (n Z 33)
6 (35.3%) 8 (47.1%) 0 (0.0%) 3 (17.6%)
16 (48.5%) 7 (21.2%) 9 (27.3%) 1 (3.0%)
Fisher Exact Test P Z .009
Volume 90 Number 1S Supplement 2014 Conclusions: Early toxicity outcomes of HDR-EBT for non-melanomatous skin cancers are encouraging with <10% acute grade 4 toxicities. However, lower extremity lesions should be treated with caution as suboptimal vascular perfusion at these sites may impede desquamated skin from healing, resulting in greater risk for ulceration. Author Disclosure: M.K. Cheung: None. Y. Kim: None. S.E. Sckolnik: None. J.L. Grow: None. B.G. Slane: None. J.D. Gordon: None. B. Stea: None.
3383 Effects of Adjuvant Radiation Therapy in Patients With Synovial Sarcoma S. Song,1 S. Kim,1 J. Park,1 H. Kim,2 and I. Kim2; 1Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea, Republic of Korea, 2Seoul National University Hospital, Seoul, Korea, Republic of Korea Purpose/Objective(s): To analyze treatment outcomes and evaluate effects of adjuvant radiation therapy (RT) in patients with synovial sarcoma. Materials/Methods: Medical records of 103 patients treated with definitive surgery with/without RT for synovial sarcoma from August 1982 to July 2013 were retrospectively reviewed. The median age of patients was 33 years (range, 5-72). Tumor locations were extremities in 79 (77%) patients. Seventy-five (73%) patients received adjuvant RT and 26 (25%) did not. The median dose of adjuvant RT was 61.2 Gy (range, 45-66.6). Results: Median follow-up duration was 6.5 years (range, 0.4-31.0). The 5- and 10-year overall survival (OS) rates were 77 % and 65%, respectively. The progression-free survival (PFS) rates at 5 and 10 years were 52% and 43%, respectively. The most common site of initial failure was lung (24 patients) followed by local recurrence (14 patients). Five-year local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) rates were 80% and 63%, respectively. On multivariate analysis, mitosis count lower than 10 per 10 high-power fields (HPF) was significant predictors of better OS, PFS, LRFS and DMFS rates (P Z 0.004, <0.001, 0.025 and <0.001, respectively). Use of adjuvant RT was additional prognostic factor for better PFS and LRFS (P Z 0.006 and 0.028, respectively). For DMFS, positive/uncheckable resection margin was also associated with poor prognosis (P Z 0.011). There was no significant difference of LRFS between higher and lower RT dose groups (less than 63 Gy group, 89% vs 63 Gy or more group, 88%, P Z 0.772). Conclusions: Lung and primary site were frequent sites of failure in patients treated with definitive surgery for synovial sarcoma. Adjuvant RT improved LRFS and PFS rates and frequent mitotic figure (Ten or more mitoses per 10 HPF) was a worse prognostic factor for these patients. Author Disclosure: S. Song: None. S. Kim: None. J. Park: None. H. Kim: None. I. Kim: None.
3384 HDR Brachytherapy for Resected Retroperitoneal Sarcoma in the Primary and Recurrent Setting A. Kumar,1 J.J. Juliano,1 R.M. Walsh,2 S. Chalikonda,2 and K. Stephans2; 1 Cleveland Clinic Foundation, Cleveland, OH, 2Cleveland Clinic, Cleveland, OH Purpose/Objective(s): As surgery alone for retroperitoneal (RP) sarcoma has a local recurrence (LR) as high as 50-80%, there is theoretical rationale but mixed clinical evidence to support the addition of radiation therapy to reduce LR. Peri-operative brachytherapy (POB) has the advantage of dose escalation using targeted radiation via catheters along with bowel displacement to reduce toxicity. We present outcomes of RP sarcoma patients treated with surgery and HDR brachytherapy alone. Materials/Methods: 11 patients diagnosed with RP sarcoma had tumor resection and Harrison-Anderson-Mick (HAM) applicator placed intraoperatively. These patients were treated with Ir-192 HDR brachytherapy over 1-3 days and subsequent removal of HAM applicator. Outcomes of all 11 patients were analyzed to assess LR. Histology was based on FNCLCC
Poster Viewing Abstracts S755 grading (1-3). A patterns of failure analysis was also done on patients with LR. Results: 6 patients were treated at primary resection, while 5 were treated for recurrent disease. Only 1 (9%) patient had a negative margin and 3 patients had no margins reported but had tumor encased in a pseudocapsule. Total HDR dose was 14 Gy / 1 fx (1), 20 Gy / 2 fx (1), 18 Gy / 2 fx (1), 21 Gy / 3 fx (5), 18 Gy / 3 fx (1), or 28 Gy / 4 fx (2) to 1 cm with prescription biological equivalent dose (BED) range: 28.8 - 47.6. Median follow up was 25 months (2-56). There were no significant toxicities reported related to POB. All five patients treated for recurrent disease developed LR, while 3 (50%) patients treated at primary resection developed LR. Median time to LR was 18 mos (27 mos primary resection, 17 mos recurrence). All 3 patients without LR had positive margins; 2 had grade 1 and 1 had grade 2 disease. There was no clear correlation between LR and dose, fractionation, or calculated BED. The patient with negative margins had LR in spite of POB. Of the 8 patients with LR, 1 (13%) LR was in the HDR field, 3 (36%) were adjacent to where the HAM applicator was placed and outside the HDR field, 2 (25%) were between loops of bowel, 1 LR was large and within both the HAM field and an adjacent site, and 1 LR had caused malignant ascites but it was difficult to determine the location of a solid component. Six (75%) LRs were outside the HDR field but in adjacent sites and would have likely been encompassed in a standard EBRT field. Conclusions: Local recurrence after POB alone is high for both primary and recurrent RP sarcomas. Based on patterns of failure analysis, we would recommend the addition of supplemental EBRT particularly for grade 3 histology and recurrent disease. Author Disclosure: A. Kumar: None. J.J. Juliano: None. R.M. Walsh: None. S. Chalikonda: None. K. Stephans: None.
3385 Prognostic Factors in Alveolar Soft-Part Sarcoma: A SEER Analysis H. Wang,1,2 A. Jacobson,1 D. Harmon,1,3 J. Michaelson,1,3 T.F. DeLaney,1,3 and Y. Chen1,3; 1Massachusetts General Hospital, Boston, MA, 2Peking Union Medical College, Beijing, China, 3Harvard Medical School, Boston, MA Purpose/Objective(s): Alveolar soft-part sarcomas (ASPS) are extremely rare soft tissue sarcomas. We analyzed the outcomes of ASPS in the Surveillance, Epidemiology, and End Result (SEER) Registry. Materials/Methods: The SEER Registry was queried for patients diagnosed of ASPS from 1973 to 2010. Kaplan-Meier analysis and Cox proportional hazards regression were used to analyze ASPS overall survival, disease specific survival, and prognostic factors. Results: A total number of 216 patients with ASPS were identified, with 123 (56.9%) female and 93 (43.1%) male. The median age was 27, with 80.6% < 35 years old. Clinically 107 (49.5%) patients presented with local-regional disease, and 91 (42.1%) with distant disease. Extremities are the most common disease site, accounting for 133 cases (62.0%). 43 (19.9%) cases were >10cm in size, 61 (28.2%) were 5-10 cm, and 49 (22.7%) were <5cm. Treatment included surgery only in 81 (37.5%) patients, radiation only in 24 (11.1%) patients, surgery + radiation in 82 (38.0%) patients and no treatment in 23 (10.7%) patients. Of the surgery + radiation group, radiation was given post-operatively for 66 cases, preoperatively for 11 cases, and other for 5 cases. The median follow-up was 49 months. The 2-, 5-, 10- year overall survival rates were 82%, 57%, and 38%, and the 2-, 5-, and 10-year DSS rates were 83%, 60%, and 40%, respectively. A Cox proportional hazards model identified older age [hazard ratio (HR) Z 1.03 per year, P Z 0.00077], male sex (HR Z 1.63, P Z 0.024), large tumor size of >10cm (HR Z 2.76, P Z 0.022), distant metastasis at diagnosis (HR Z 3.23, P Z 0.00004), trunk as primary tumor site (HR Z 2.06, P Z 0.00349), no treatment group (HR Z 2.1, P Z 0.01861) and only radiation without surgery (HR Z 2.9, P Z 0.00232) as independent factors affecting OS and DSS. Finally, use of adjuvant radiation therapy with surgery was not seen as a predictor of improved OS and DSS (P Z 0.13 and P Z 0.28), respectively.