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A SEER Database Analysis of Urethral Cancer Management
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Volume 84 Number 3S Supplement 2012 Chained multiple imputation was performed to account for missing data and a multivariate Cox hazards regression was used for testing significance. Results: IORT was delivered during nephrectomy for advanced disease (28% of patients) or during resection of locally recurrent RCC in the renal fossa (72%). Sixty-nine percent of patients were male and the mean age at RCC diagnosis was 57. At initial nephrectomy, primary T-stage was 17% T1, 12% T2, 55% T3, and 16% T4. Prior to IORT, 87% had a visibly complete surgical resection of tumor. Mean IORT dose delivered was 14.7 Gy (range, 9-20 Gy). Average length of post-op hospitalization was 10.7 days. Pre-operative or post-operative external beam radiation therapy (EBRT) was administered to 27% and 35% of patients, respectively (2% received both pre and post-operative EBRT). Median follow-up after IORT was 1.6 years. OS at 1 and 5 years after IORT was 69% and 37% for advanced patients and 94% and 55% for locally recurrent patients, respectively. DFS at 1 and 5 years was 72% and 39% for advanced patients and 96% and 52% for locally recurrent patients, respectively. DSS at 1 and 5 years was 72% and 41% for advanced patients and 96% and 60% for locally recurrent patients, respectively. For the entire cohort, higher IORT dose (HR 1.3, p < 0.001), positive initial nodal status (HR 2.9-3.6, p < 0.01), and presence of sarcomatoid features (HR 3.7-6.9, p < 0.05) had a statistically significant association with decreased OS, DFS and DSS. Patients who received adjuvant systemic therapy after IORT showed decreased DSS (HR 2.4, p Z 0.03). When analyzing locally recurrent tumors alone, positive margin status (HR 2.6, p Z 0.01) was associated with decreased OS. Conclusion: We report on the largest known cohort of patients with RCC managed with IORT and we have identified several factors associated with survival. Outcomes in our cohort of patients with locally recurrent RCC treated with local resection and IORT compare favorably to similar groups treated with local resection alone suggesting improved DSS may be possible with IORT. Author Disclosure: J.J. Paly: None. C.L. Hallemeier: None. P.J. Biggs: None. A. Niemierko: None. F. Roeder: None. R. Martı´nez-Monge: None. J.M. Whitson: None. F.A. Calvo: None. G. Fastner: None. J.A. Efstathiou: None.
2549 A SEER Database Analysis of Urethral Cancer Management C. Zhang,1 S. Wang,2 and I. Deutsch1; 1Department of Radiation Oncology, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, 2Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY Purpose/Objective(s): Urethral cancer comprises less than 1% of malignancies. Large series are not available to inform best practices. Our analysis was conducted with the intent of providing additional information about this disease. Materials/Methods: Patients with urethral cancer diagnosed between 1973 and 2008 were identified in the Surveillance, Epidemiology and End Results (SEER) database. The influences of demographic characteristics and treatment modality on outcome were analyzed. Results: A total of 2,872 invasive and 1,237 in situ cases were identified. Of the invasive, 55% are transitional cell carcinoma (TCC), 21% squamous cell carcinoma (SCC), 15% adenocarcinoma or adenosquamous carcinoma, 9% unknown and other histology. Median survival time for in situ disease is 78 months, stage I (n Z 231) 49 months, stage II (n Z 120) 38 months, stage III (n Z 91) 38 months, and stage IV excluding M1 36 months. Treatment modality was stratified into 4 groups: Surgery only (SO), surgery and radiation (SRT), radiation only (RO), and no surgery or radiation (XX). SO was used to treat the majority of patients, especially males (92%), and those with in situ (86%) or stage I (78%) disease. Four hundred ninety-nine invasive cases were identified that were M0, completely staged, and with data on treatment modality used. All of these cases were diagnosed between 2004-2008, with median follow-up of 33 months. These cases were treated as follows: SO n Z 339, SRT n
Z 80, RO n Z 32, XX n Z 48. On univariate analysis, worse cause specific survival (CSS) is associated with higher stage, grade, large tumor size, adenocarcinoma histology, female sex and diagnosis before 1998. SRT patients have a higher percentage of these poor prognostic factors than SO patients, indicating a different referral pattern for adjuvant radiation therapy between these two groups. Multivariate analysis showed overall better CSS in SO versus SRT (80% vs. 48%, p Z 0.007). Significantly better 5-year overall survival (OS) and CSS were seen in SO versus SRT in patients who had gross total resection (GTR) (OS: 25% vs. 0%, p Z 0.022; CSS: 73% vs. 20%, p Z 0.003) or with partial tumor resection (PTR) (OS: 30% vs. 13%, p Z 0.033; CSS: 77% vs. 52%, p Z 0.025). Conclusions: Based on available SEER data, with its inherent shortcomings, we have found no evidence that adding radiation to surgery improves OS or CSS for invasive urethral cancer. However, the magnitude of the difference in survival between SO and SRT in PTR is much smaller than for GTR. We believe that this indicates a necessity for further studies on subgroups of PTR, such as those with proximal urethral cancer, which may benefit from adjuvant radiation. Author Disclosure: C. Zhang: None. S. Wang: None. I. Deutsch: None.
2550 Outcomes in Stage I and IIA-B Testicular Seminoma Patients Treated With Dog-leg Field Radiation Therapy (DLRT) K. Kalakota,1 J.A. Kalapurakal,1 I. Helenowski,2 and S.V. Sejpal1; 1 Department of Radiation Oncology, Northwestern University, Chicago, IL, 2Northwestern University, Feinberg School of Medicine, Chicago, IL Purpose/Objective(s): To examine local control rates and patterns of failure in patients with Stage I and Stage IIA-B testicular seminoma treated with dog-leg field radiation therapy (DLRT). Materials/Methods: Between 1990 and 2011, 104 patients evaluable for this analysis were seen in the department of Radiation Oncology with Stage I and IIA-B testicular seminoma. All patients underwent an orchiectomy, and for those who received radiation therapy (RT), a dog-leg field encompassing the paraortic (PA) and ipsilateral pelvic nodes was used. Results: Eighty-eight patients had stage I disease, 16 patients had stage II disease. Median follow-up for the whole cohort was 52.4 months (range, 2.6-199.7). For men with stage I disease, 67 patients (76%) received adjuvant RT to a mean dose of 25.5 Gy and 21 patients (24%) underwent active surveillance (AS). For stage I patients who received RT, there were no local or distant failures. For patients who chose AS, at a median followup of 34.4 months (range, 2.6-104.8), 2 patients (10%) relapsed, at 8 and 36 months, both in the PA nodes. One patient had a tumor size > 4cm and the other had rete testis involvement. Both of these patients were salvaged successfully with RT. For men with stage II disease, all 16 patients (12 with Stage IIA, and 4 with Stage IIB) received adjuvant radiation therapy. Mean dose for Stage IIA was 30 Gy, and for stage IIB it was 35 Gy. All patients presented with a PA node and one patient had both PA and pelvic nodes. Three patients (19%) relapsed distantly; 1 in the mediastinum, 1 in the supraclavicular region and mediastinum, and 1 with a soft tissue mass in the rib. There were no local failures in the radiation field. All 3 patients were salvaged successfully with chemotherapy. Neither age (p Z 0.31), size of tumor (p Z 0.53), elevated pre-operative tumor markers (p Z 0.79), presence of rete testis (p Z 0.67) or lymphovascular invasion (p Z 0.54) predicted for failure in patients with AS or Stage II disease. OS for all evaluated patients is 100%. Conclusions: Stage I and IIA-B testicular seminoma patients treated with a DLRT field had a 100% local control rate in the radiation treatment field. In stage II patients, 19% failed distantly and all were successfully salvaged with chemotherapy. Adjuvant radiation therapy remains an effective option in stage I and IIA-B seminoma patients with excellent outcomes. Author Disclosure: K. Kalakota: None. J.A. Kalapurakal: None. I. Helenowski: None. S.V. Sejpal: None.
Volume 84 Number 3S Supplement 2012 Chained multiple imputation was performed to account for missing data and a multivariate Cox hazards regression was used for testing significance. Results: IORT was delivered during nephrectomy for advanced disease (28% of patients) or during resection of locally recurrent RCC in the renal fossa (72%). Sixty-nine percent of patients were male and the mean age at RCC diagnosis was 57. At initial nephrectomy, primary T-stage was 17% T1, 12% T2, 55% T3, and 16% T4. Prior to IORT, 87% had a visibly complete surgical resection of tumor. Mean IORT dose delivered was 14.7 Gy (range, 9-20 Gy). Average length of post-op hospitalization was 10.7 days. Pre-operative or post-operative external beam radiation therapy (EBRT) was administered to 27% and 35% of patients, respectively (2% received both pre and post-operative EBRT). Median follow-up after IORT was 1.6 years. OS at 1 and 5 years after IORT was 69% and 37% for advanced patients and 94% and 55% for locally recurrent patients, respectively. DFS at 1 and 5 years was 72% and 39% for advanced patients and 96% and 52% for locally recurrent patients, respectively. DSS at 1 and 5 years was 72% and 41% for advanced patients and 96% and 60% for locally recurrent patients, respectively. For the entire cohort, higher IORT dose (HR 1.3, p < 0.001), positive initial nodal status (HR 2.9-3.6, p < 0.01), and presence of sarcomatoid features (HR 3.7-6.9, p < 0.05) had a statistically significant association with decreased OS, DFS and DSS. Patients who received adjuvant systemic therapy after IORT showed decreased DSS (HR 2.4, p Z 0.03). When analyzing locally recurrent tumors alone, positive margin status (HR 2.6, p Z 0.01) was associated with decreased OS. Conclusion: We report on the largest known cohort of patients with RCC managed with IORT and we have identified several factors associated with survival. Outcomes in our cohort of patients with locally recurrent RCC treated with local resection and IORT compare favorably to similar groups treated with local resection alone suggesting improved DSS may be possible with IORT. Author Disclosure: J.J. Paly: None. C.L. Hallemeier: None. P.J. Biggs: None. A. Niemierko: None. F. Roeder: None. R. Martı´nez-Monge: None. J.M. Whitson: None. F.A. Calvo: None. G. Fastner: None. J.A. Efstathiou: None.
2549 A SEER Database Analysis of Urethral Cancer Management C. Zhang,1 S. Wang,2 and I. Deutsch1; 1Department of Radiation Oncology, New York Presbyterian Hospital - Columbia University Medical Center, New York, NY, 2Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY Purpose/Objective(s): Urethral cancer comprises less than 1% of malignancies. Large series are not available to inform best practices. Our analysis was conducted with the intent of providing additional information about this disease. Materials/Methods: Patients with urethral cancer diagnosed between 1973 and 2008 were identified in the Surveillance, Epidemiology and End Results (SEER) database. The influences of demographic characteristics and treatment modality on outcome were analyzed. Results: A total of 2,872 invasive and 1,237 in situ cases were identified. Of the invasive, 55% are transitional cell carcinoma (TCC), 21% squamous cell carcinoma (SCC), 15% adenocarcinoma or adenosquamous carcinoma, 9% unknown and other histology. Median survival time for in situ disease is 78 months, stage I (n Z 231) 49 months, stage II (n Z 120) 38 months, stage III (n Z 91) 38 months, and stage IV excluding M1 36 months. Treatment modality was stratified into 4 groups: Surgery only (SO), surgery and radiation (SRT), radiation only (RO), and no surgery or radiation (XX). SO was used to treat the majority of patients, especially males (92%), and those with in situ (86%) or stage I (78%) disease. Four hundred ninety-nine invasive cases were identified that were M0, completely staged, and with data on treatment modality used. All of these cases were diagnosed between 2004-2008, with median follow-up of 33 months. These cases were treated as follows: SO n Z 339, SRT n
Z 80, RO n Z 32, XX n Z 48. On univariate analysis, worse cause specific survival (CSS) is associated with higher stage, grade, large tumor size, adenocarcinoma histology, female sex and diagnosis before 1998. SRT patients have a higher percentage of these poor prognostic factors than SO patients, indicating a different referral pattern for adjuvant radiation therapy between these two groups. Multivariate analysis showed overall better CSS in SO versus SRT (80% vs. 48%, p Z 0.007). Significantly better 5-year overall survival (OS) and CSS were seen in SO versus SRT in patients who had gross total resection (GTR) (OS: 25% vs. 0%, p Z 0.022; CSS: 73% vs. 20%, p Z 0.003) or with partial tumor resection (PTR) (OS: 30% vs. 13%, p Z 0.033; CSS: 77% vs. 52%, p Z 0.025). Conclusions: Based on available SEER data, with its inherent shortcomings, we have found no evidence that adding radiation to surgery improves OS or CSS for invasive urethral cancer. However, the magnitude of the difference in survival between SO and SRT in PTR is much smaller than for GTR. We believe that this indicates a necessity for further studies on subgroups of PTR, such as those with proximal urethral cancer, which may benefit from adjuvant radiation. Author Disclosure: C. Zhang: None. S. Wang: None. I. Deutsch: None.
2550 Outcomes in Stage I and IIA-B Testicular Seminoma Patients Treated With Dog-leg Field Radiation Therapy (DLRT) K. Kalakota,1 J.A. Kalapurakal,1 I. Helenowski,2 and S.V. Sejpal1; 1 Department of Radiation Oncology, Northwestern University, Chicago, IL, 2Northwestern University, Feinberg School of Medicine, Chicago, IL Purpose/Objective(s): To examine local control rates and patterns of failure in patients with Stage I and Stage IIA-B testicular seminoma treated with dog-leg field radiation therapy (DLRT). Materials/Methods: Between 1990 and 2011, 104 patients evaluable for this analysis were seen in the department of Radiation Oncology with Stage I and IIA-B testicular seminoma. All patients underwent an orchiectomy, and for those who received radiation therapy (RT), a dog-leg field encompassing the paraortic (PA) and ipsilateral pelvic nodes was used. Results: Eighty-eight patients had stage I disease, 16 patients had stage II disease. Median follow-up for the whole cohort was 52.4 months (range, 2.6-199.7). For men with stage I disease, 67 patients (76%) received adjuvant RT to a mean dose of 25.5 Gy and 21 patients (24%) underwent active surveillance (AS). For stage I patients who received RT, there were no local or distant failures. For patients who chose AS, at a median followup of 34.4 months (range, 2.6-104.8), 2 patients (10%) relapsed, at 8 and 36 months, both in the PA nodes. One patient had a tumor size > 4cm and the other had rete testis involvement. Both of these patients were salvaged successfully with RT. For men with stage II disease, all 16 patients (12 with Stage IIA, and 4 with Stage IIB) received adjuvant radiation therapy. Mean dose for Stage IIA was 30 Gy, and for stage IIB it was 35 Gy. All patients presented with a PA node and one patient had both PA and pelvic nodes. Three patients (19%) relapsed distantly; 1 in the mediastinum, 1 in the supraclavicular region and mediastinum, and 1 with a soft tissue mass in the rib. There were no local failures in the radiation field. All 3 patients were salvaged successfully with chemotherapy. Neither age (p Z 0.31), size of tumor (p Z 0.53), elevated pre-operative tumor markers (p Z 0.79), presence of rete testis (p Z 0.67) or lymphovascular invasion (p Z 0.54) predicted for failure in patients with AS or Stage II disease. OS for all evaluated patients is 100%. Conclusions: Stage I and IIA-B testicular seminoma patients treated with a DLRT field had a 100% local control rate in the radiation treatment field. In stage II patients, 19% failed distantly and all were successfully salvaged with chemotherapy. Adjuvant radiation therapy remains an effective option in stage I and IIA-B seminoma patients with excellent outcomes. Author Disclosure: K. Kalakota: None. J.A. Kalapurakal: None. I. Helenowski: None. S.V. Sejpal: None.