- Email: [email protected]
– Chemotherapy for Non-Small Cell Lung Cancer
Digital Poster Discussion Abstracts S161
Volume 90 Number 1S Supplement 2014 radiosurgery or Linac-based coplanar IMRT or VMAT treatment plans. Median follow-up imaging was 14 months. The presence or absence of fracture was identified from the most recent CT scan then compared to pretreatment and follow-up scans. Results: Of 236 patients reviewed 27 had thoracic vertebral compression fractures. Ten of the 27 patients developed fractures after radiation therapy and 7 were at the same vertebral level as the treated lesion. Treatment doses for these patients ranged from 20/1, 25/1, 30/1, 50/4, and 54 Gy/3 fractions. Fractures occurred between 7 and 28 months after SABR in the 7 patients. Two of the 7 patients had pre-existing thoracic fractures and 2 of the patients developed at least one fracture during the follow-up period at a vertebral level that did not receive radiation dose. Two of the 7 patients had rib fractures attributed to radiation dose. There were a total of 8 fractures as one patient had 3 lesions treated and 2 different vertebral levels affected. Six of the 7 patients were women and ages ranged from 64-89. CT scans revealed diffuse osteopenia in each of the patients. Four of the PTVs were 6-10 cm from the affected vertebral body and the other 3 PTVs abutted the affected vertebral body. Conclusions: Vertebral fractures after SABR to cancers in the lung are infrequent but may be associated with radiation dose. Patients at greatest risk appear to be postmenopausal women with diffuse osteopenia. With increased numbers and dosimetric evaluation we may soon be able to better define discrete risks. Understanding these risks and limiting vertebral body dose in high-risk patients could help avoid potentially severe fractures. Author Disclosure: T.A. Aguilera: None. N. Trakul: None. D. Shultz: None. P.G. Maxim: E. Research Grant; Varian, RaySearch. F. Honoraria; Varian. M. Diehn: E. Research Grant; Varian. B.W. Loo: E. Research Grant; Varian, RaySearch. F. Honoraria; Varian.
1009 Cardiac Events After Treatment With High-Dose Radiation Therapy +/e Chemotherapy for Non-Small Cell Lung Cancer L. Tang,1,2 A. Liu,3 D.R. Gomez,1 Q. Nguyen,1 T. Xu,1 R.U. Komaki,1 and Z. Liao1; 1University of Texas MD Anderson Cancer Center, Houston, TX, 2Sun Yat-sen University Cancer Center, Guangzhou, China, 3The Second Affiliated Hospital, Nanchang University, Nanchang, China Purpose/Objective(s): Cardiac events after high-dose radiation therapy (RT) for non-small cell lung cancer (NSCLC) have not been reported comprehensively. We performed a detailed analysis of cardiac toxicity that occurred in a cohort of patients treated with definitive doses of RT in this context. Materials/Methods: This study included 303 NSCLC patients who received RT (dose 60 Gy) from April 1, 2004 through May 31, 2010 at a single institution. The median radiation prescription dose was 70 Gy (range, 60-87.5 Gy). The median value of the mean heart dose (MHD) was 11.4 Gy (range, 0-52.4 Gy). Thirty-two percent of patients (n Z 96) received induction chemotherapy, 84.8% (n Z 257) received concurrent chemotherapy, and 20.8% (n Z 63) received adjuvant chemotherapy. Preexisting cardiac conditions included myocardial ischemia in 15.8% of patients (n Z 48), arrhythmia in 9.9% (n Z 30), hypertension in 49.5% (n Z 150), and diabetes mellitus in 13.2% (n Z 40). Cardiac toxicity was defined as having any previously undocumented cardiac event occurring after the start of radiation therapy, and was classified into five categories: myocardium ischemia, pericarditis, arrhythmia, heart failure, and valve abnormalities, each scored according to the CTCAE v4.0 system. Patients that were diagnosed with new cardiac events after RT were compared with those that were not using the chi-squared test. Then, the cumulative incidence of each category of cardiac events according to different MHD was compared using the log-rank test. Results: Fifty-three percent of patients (n Z 161) in the entire patient cohort were found to have a new cardiac diagnosis after RT. The incidence of new-onset myocardial ischemia, pericarditis, arrhythmia, heart failure and valve abnormalities were 5.6%, 39.3%, 11.9%, 4.0%, and 17.2%, respectively. The median time to develop grade 2 or above myocardial ischemia, pericarditis, arrhythmia, heart failure, and valve abnormalities
was 8.8, 8.6, 7.7, 4.8, and 9.6 months, respectively. Patients with new cardiac diagnoses after RT did not differ from those without new cardiac events with respect to age, sex, stage (I-II vs III-IV vs recurrence), laterality of tumor (right vs left), smoking, alcohol history, prior cardiac disease, or RT technique (p > 0.05 for all). With regard to specific cardiac events, the use of concurrent chemotherapy and adjuvant chemotherapy (OR Z 2.31, 95% CI: 1.12-4.74, p Z 0.02; OR Z 2.14, 95% CI: 1.223.75, p Z 0.01) was associated with pericarditis, while a MHD of 22.6 Gy or higher was correlated with the cumulative incidence of post-RT myocardial ischemia (p Z 0.02). Conclusions: The incidence of developing cardiac events after high-dose RT for NSCLC is approximately 50%, with the most common events being myocardial ischemia, pericarditis, and arrhythmia. Treatment-specific correlations with specific event types may be due to differing mechanisms of each of these modalities. Author Disclosure: L. Tang: None. A. Liu: None. D.R. Gomez: None. Q. Nguyen: None. T. Xu: None. R.U. Komaki: None. Z. Liao: None.
1010 Evaluating a Nomogram for the Development of Radiation Pneumonitis in Locally Advanced Non-Small Cell Lung Cancer Treated With 3D and Intensity Modulated Radiation Therapy S. Rehman,1 C.K. Speirs,1 A. Molotievschi,2 D. Mullen,1 S. Fergus,1 T.A. DeWees,1 M.A. Velez,1 J.D. Bradley,1 and C.G. Robinson1; 1 Washington University, St. Louis, MO, 2Barretos Cancer Hospital, Barretos, Brazil Purpose/Objective(s): Radiation pneumonitis (RP) is a dose-limiting late toxicity in thoracic irradiation. A previously published nomogram, which incorporates total lung mean dose and tumor superior-inferior lung location, developed at our institution has been developed to predict the risk of RP for patients treated with definitive 3D conformal radiation therapy (3DCRT) for locally advanced non-small cell lung cancer (NSCLC) prior to 2001. In this study, we tested the nomogram on a more modern cohort of patients, including patients treated with intensity modulated radiation therapy (IMRT). Risk factors for developing RP were also evaluated. Materials/Methods: Patients treated using either 3DCRT or IMRT for locally advanced NSCLC from 2001 to 2012 were queried. Clinical, tumor, and dosimetric information were collected. Log-rank test was used to determine predictors of grade 2 or higher RP, based on Common Terminology Criteria for Adverse Events version 4.0. RP risk was determined based on a previously published nomogram predicting for RP. Spearman’s rank correlation was performed based on the calculated risk of RP versus the actual rate of RP. Results: The entire cohort included 340 patients, including 277 (81%) patients treated with 3DCRT and 63 (19%) patients treated with IMRT. Median age of patients was 65 years. The raw rate of grade 2 or higher RP was 35% (35% for patients treated with 3DCRT; 32% for patients treated with IMRT). For the entire cohort, on univariate analysis, use of adjuvant chemotherapy, former smoking status, heart mean dose, heart volume receiving 5-55 Gray (Gy), total lung volume minus planning target volume receiving 35-50 Gy, and RP risk nomogram score were predictive of increased risk of RP; current smoking was protective of RP. On multivariate analysis, heart volume receiving 35 Gy [odds ratio (OR): 1.018, 95% confidence interval (CI): 1.004-1.033, p Z 0.012] was predictive for increased risk of RP and current smoking (OR: 0.369, 95% CI: 0.1920.709, p Z 0.0008) was predictive for decreased risk of RP. Spearman’s rank correlation for RP risk nomogram score showed r Z 0.208 (p Z 0.001) for the entire cohort. For patients treated with 3DCRT, r Z 0.225 (p Z 0.0014); for patients treated with IMRT, r Z 0.161 (p Z 0.26). Conclusions: The dose to the heart is predictive for the risk of RP. The previously published nomogram for predicting RP in locally advanced NSCLC is validated for patients treated with 3DCRT, although it loses predictive power compared to the previously published data, which had r Z 0.28. For patients treated with IMRT, the nomogram was not validated and future studies will help develop a new model for this cohort of patients, particularly evaluating heart dosimetric information.
Volume 90 Number 1S Supplement 2014 radiosurgery or Linac-based coplanar IMRT or VMAT treatment plans. Median follow-up imaging was 14 months. The presence or absence of fracture was identified from the most recent CT scan then compared to pretreatment and follow-up scans. Results: Of 236 patients reviewed 27 had thoracic vertebral compression fractures. Ten of the 27 patients developed fractures after radiation therapy and 7 were at the same vertebral level as the treated lesion. Treatment doses for these patients ranged from 20/1, 25/1, 30/1, 50/4, and 54 Gy/3 fractions. Fractures occurred between 7 and 28 months after SABR in the 7 patients. Two of the 7 patients had pre-existing thoracic fractures and 2 of the patients developed at least one fracture during the follow-up period at a vertebral level that did not receive radiation dose. Two of the 7 patients had rib fractures attributed to radiation dose. There were a total of 8 fractures as one patient had 3 lesions treated and 2 different vertebral levels affected. Six of the 7 patients were women and ages ranged from 64-89. CT scans revealed diffuse osteopenia in each of the patients. Four of the PTVs were 6-10 cm from the affected vertebral body and the other 3 PTVs abutted the affected vertebral body. Conclusions: Vertebral fractures after SABR to cancers in the lung are infrequent but may be associated with radiation dose. Patients at greatest risk appear to be postmenopausal women with diffuse osteopenia. With increased numbers and dosimetric evaluation we may soon be able to better define discrete risks. Understanding these risks and limiting vertebral body dose in high-risk patients could help avoid potentially severe fractures. Author Disclosure: T.A. Aguilera: None. N. Trakul: None. D. Shultz: None. P.G. Maxim: E. Research Grant; Varian, RaySearch. F. Honoraria; Varian. M. Diehn: E. Research Grant; Varian. B.W. Loo: E. Research Grant; Varian, RaySearch. F. Honoraria; Varian.
1009 Cardiac Events After Treatment With High-Dose Radiation Therapy +/e Chemotherapy for Non-Small Cell Lung Cancer L. Tang,1,2 A. Liu,3 D.R. Gomez,1 Q. Nguyen,1 T. Xu,1 R.U. Komaki,1 and Z. Liao1; 1University of Texas MD Anderson Cancer Center, Houston, TX, 2Sun Yat-sen University Cancer Center, Guangzhou, China, 3The Second Affiliated Hospital, Nanchang University, Nanchang, China Purpose/Objective(s): Cardiac events after high-dose radiation therapy (RT) for non-small cell lung cancer (NSCLC) have not been reported comprehensively. We performed a detailed analysis of cardiac toxicity that occurred in a cohort of patients treated with definitive doses of RT in this context. Materials/Methods: This study included 303 NSCLC patients who received RT (dose 60 Gy) from April 1, 2004 through May 31, 2010 at a single institution. The median radiation prescription dose was 70 Gy (range, 60-87.5 Gy). The median value of the mean heart dose (MHD) was 11.4 Gy (range, 0-52.4 Gy). Thirty-two percent of patients (n Z 96) received induction chemotherapy, 84.8% (n Z 257) received concurrent chemotherapy, and 20.8% (n Z 63) received adjuvant chemotherapy. Preexisting cardiac conditions included myocardial ischemia in 15.8% of patients (n Z 48), arrhythmia in 9.9% (n Z 30), hypertension in 49.5% (n Z 150), and diabetes mellitus in 13.2% (n Z 40). Cardiac toxicity was defined as having any previously undocumented cardiac event occurring after the start of radiation therapy, and was classified into five categories: myocardium ischemia, pericarditis, arrhythmia, heart failure, and valve abnormalities, each scored according to the CTCAE v4.0 system. Patients that were diagnosed with new cardiac events after RT were compared with those that were not using the chi-squared test. Then, the cumulative incidence of each category of cardiac events according to different MHD was compared using the log-rank test. Results: Fifty-three percent of patients (n Z 161) in the entire patient cohort were found to have a new cardiac diagnosis after RT. The incidence of new-onset myocardial ischemia, pericarditis, arrhythmia, heart failure and valve abnormalities were 5.6%, 39.3%, 11.9%, 4.0%, and 17.2%, respectively. The median time to develop grade 2 or above myocardial ischemia, pericarditis, arrhythmia, heart failure, and valve abnormalities
was 8.8, 8.6, 7.7, 4.8, and 9.6 months, respectively. Patients with new cardiac diagnoses after RT did not differ from those without new cardiac events with respect to age, sex, stage (I-II vs III-IV vs recurrence), laterality of tumor (right vs left), smoking, alcohol history, prior cardiac disease, or RT technique (p > 0.05 for all). With regard to specific cardiac events, the use of concurrent chemotherapy and adjuvant chemotherapy (OR Z 2.31, 95% CI: 1.12-4.74, p Z 0.02; OR Z 2.14, 95% CI: 1.223.75, p Z 0.01) was associated with pericarditis, while a MHD of 22.6 Gy or higher was correlated with the cumulative incidence of post-RT myocardial ischemia (p Z 0.02). Conclusions: The incidence of developing cardiac events after high-dose RT for NSCLC is approximately 50%, with the most common events being myocardial ischemia, pericarditis, and arrhythmia. Treatment-specific correlations with specific event types may be due to differing mechanisms of each of these modalities. Author Disclosure: L. Tang: None. A. Liu: None. D.R. Gomez: None. Q. Nguyen: None. T. Xu: None. R.U. Komaki: None. Z. Liao: None.
1010 Evaluating a Nomogram for the Development of Radiation Pneumonitis in Locally Advanced Non-Small Cell Lung Cancer Treated With 3D and Intensity Modulated Radiation Therapy S. Rehman,1 C.K. Speirs,1 A. Molotievschi,2 D. Mullen,1 S. Fergus,1 T.A. DeWees,1 M.A. Velez,1 J.D. Bradley,1 and C.G. Robinson1; 1 Washington University, St. Louis, MO, 2Barretos Cancer Hospital, Barretos, Brazil Purpose/Objective(s): Radiation pneumonitis (RP) is a dose-limiting late toxicity in thoracic irradiation. A previously published nomogram, which incorporates total lung mean dose and tumor superior-inferior lung location, developed at our institution has been developed to predict the risk of RP for patients treated with definitive 3D conformal radiation therapy (3DCRT) for locally advanced non-small cell lung cancer (NSCLC) prior to 2001. In this study, we tested the nomogram on a more modern cohort of patients, including patients treated with intensity modulated radiation therapy (IMRT). Risk factors for developing RP were also evaluated. Materials/Methods: Patients treated using either 3DCRT or IMRT for locally advanced NSCLC from 2001 to 2012 were queried. Clinical, tumor, and dosimetric information were collected. Log-rank test was used to determine predictors of grade 2 or higher RP, based on Common Terminology Criteria for Adverse Events version 4.0. RP risk was determined based on a previously published nomogram predicting for RP. Spearman’s rank correlation was performed based on the calculated risk of RP versus the actual rate of RP. Results: The entire cohort included 340 patients, including 277 (81%) patients treated with 3DCRT and 63 (19%) patients treated with IMRT. Median age of patients was 65 years. The raw rate of grade 2 or higher RP was 35% (35% for patients treated with 3DCRT; 32% for patients treated with IMRT). For the entire cohort, on univariate analysis, use of adjuvant chemotherapy, former smoking status, heart mean dose, heart volume receiving 5-55 Gray (Gy), total lung volume minus planning target volume receiving 35-50 Gy, and RP risk nomogram score were predictive of increased risk of RP; current smoking was protective of RP. On multivariate analysis, heart volume receiving 35 Gy [odds ratio (OR): 1.018, 95% confidence interval (CI): 1.004-1.033, p Z 0.012] was predictive for increased risk of RP and current smoking (OR: 0.369, 95% CI: 0.1920.709, p Z 0.0008) was predictive for decreased risk of RP. Spearman’s rank correlation for RP risk nomogram score showed r Z 0.208 (p Z 0.001) for the entire cohort. For patients treated with 3DCRT, r Z 0.225 (p Z 0.0014); for patients treated with IMRT, r Z 0.161 (p Z 0.26). Conclusions: The dose to the heart is predictive for the risk of RP. The previously published nomogram for predicting RP in locally advanced NSCLC is validated for patients treated with 3DCRT, although it loses predictive power compared to the previously published data, which had r Z 0.28. For patients treated with IMRT, the nomogram was not validated and future studies will help develop a new model for this cohort of patients, particularly evaluating heart dosimetric information.