- Email: [email protected]
Regional Recurrence in Resected Non-small Cell Lung Cancer?
Proceedings of the 53rd Annual ASTRO Meeting Results: Median time between implantation and simulation was 8 days (range 5 - 248 days). Results are reported per lesion and per marker. Median individual marker migration was 1.3 mm, 1.5 and 1.2 mm for seeds and coils, respectively. Median FRE across lesions was 1.6 mm, 1.9 and 1.3 mm for seeds and coils, respectively. Interquartile (25 - 75%-ile) range of FRE was 0.9 - 3 mm. The corresponding values when aligning with outlier exclusion were 1.0 mm median individual marker migration (0.7 for seeds, 1.2 for coils) and 2 mm median FRE (1.7 for seeds, 2.1 for coils). The differences between seeds and coils were not statistically significant. Of note, this analysis does not exclude the possibility that some of the apparent migration was due to breathing-induced tissue deformation. Conclusions: We previously reported that retention of implanted markers is significantly higher for coils compared to seeds. This analysis suggests that once retained, further marker migration is of small magnitude between the times of implantation and simulation, regardless of marker type. When tracking tumors by markers, marker migration appears unlikely to result in geometric miss. Author Disclosure: J.C. Hong: None. N.C.W. Eclov: None. Y. Yu: None. A.K. Rao: None. S. Dieterich: None. P.G. Maxim: None. Q. Le: None. M. Diehn: None. N. Kothary: None. B.W. Loo: D. Speakers Bureau/Honoraria; Varian, GE Medical Systems.
2772
Withholding Stereotactic Radiotherapy in Elderly Patients with Stage I Non-small Cell Lung Cancer and Co-existing COPD is not Justified: Outcomes of a Markov Model Analysis
A. V. Louie1, G. Rodrigues1, M. Hannouf1, F. Lagerwaard2, D. Palma1, G. S. Zaric1, C. J. A. Haasbeek2, S. Senan2 1
University of Western Ontario, London, ON, Canada, 2VU University Medical Center, Amsterdam, Netherlands
Purpose/Objective(s): To compare outcomes in elderly COPD patients with Stage I non-small cell lung cancer (NSCLC) treated with either stereotactic body radiation therapy (SBRT) or best supportive care (BSC). While high cure rates with low toxicity have been reported after SBRT in elderly patients, severe COPD is often cited as a reason for withholding SBRT from these patients. Materials/Methods: A Markov model was constructed to simulate the quality adjusted life expectancy (QALE) and overall survival in patients $75 years undergoing either SBRT or BSC for a 5-year timeframe. For SBRT, the rates of local, regional and distant recurrences were obtained from 247 patients entered into a prospective cohort at the VUMC, Amsterdam. Recurrences were converted into monthly transition probabilities and stratified into 4 groups according to T stage and COPD GOLD score. The 4 patient groups were: I (T1, GOLD I-II), II (T2, GOLD I-II), III (T1, GOLD III-IV), and IV (T2 GOLD III-IV). For untreated patients, overall survival by T stage was modeled according to 1,432 untreated patients from the California Cancer Registry. Markov state utilities consistent with the four stages of the AJCC staging system and COPD status based on GOLD score, were extracted and adapted from the literature. Results: Our Markov model showed a close correlation with overall survival data for all 4 groups treated with SBRT, with differences at 5 years ranging from 0.1% to 1.5%. For untreated patients, the differences were 0.1% for T1 patients and 2.2% for T2 patients at 5 years. After SBRT, 5-year overall survival ranged from 6.8% to 47.2% and QALE ranging from 14.9 to 27.4 quality adjusted life months (QALMs). 5-year overall survival for untreated T1 and T2 patients was 9.0% and 2.8%, and 10.1 and 6.1 QALMs, respectively. Outcomes were not sensitive to the quality of life post-SBRT or the disutility of disease progression in untreated patients. The relative benefit of SBRT over BSC appears to be least for group IV patients. Conclusions: In elderly patients with COPD, our Markov model predicts superior overall and QALE at 5 years after SBRT when compared to no treatment. Advanced age, COPD, and tumor size should not preclude such patients from curative SBRT. Author Disclosure: A.V. Louie: None. G. Rodrigues: None. M. Hannouf: None. F. Lagerwaard: None. D. Palma: None. G.S. Zaric: None. C.J.A. Haasbeek: None. S. Senan: D. Speakers Bureau/Honoraria; Varian Medical Systems Inc.
2773
Does SUVmax of the Primary Tumor Predict Regional Lymph Node Involvement or Local/Regional Recurrence in Resected Non-small Cell Lung Cancer?
J. M. Pepek, J. P. Chino, K. A. Higgins, D. S. Yoo, C. R. Kelsey Duke University Medical Center, Durham, NC Purpose/Objective(s): 18-fluorine fluorodeoxyglucose positron emission tomography (PET) is increasingly utilized to stage non-small cell lung cancer (NSCLC). Several studies have shown that the maximum standardized uptake value (SUVmax) of the primary tumor is prognostic for overall survival, though this remains controversial. This analysis evaluated whether SUVmax of the primary tumor independently predicts for regional lymph node involvement (pN1-N2) and for subsequent local/regional recurrence (LRR). Materials/Methods: All patients with resected Stage I-IIIA NSCLC between 1995 and 2008 who did not receive any preoperative therapy and had a preoperative PET with a reported SUVmax of the primary tumor were evaluated from a single institution database. Those without any lymph node sampling were excluded when evaluating factors associated with regional lymph node involvement. Patients who received postoperative radiation therapy or had positive surgical margins were excluded when evaluating factors associated with LRR. Disease recurrence at the surgical margin or within ipsilateral hilar and/or mediastinal lymph nodes was considered a LRR. Disease recurrence in the contralateral hilum, supraclavicular fossae, ipsilateral lung parenchyma, or elsewhere was defined as a distant metastasis. Univariate and multivariate analyses, using the median SUVmax of our cohort as a threshold (SUVmax 9.7) and SUVmax as a continuous variable, were performed to evaluate independent risk factors of regional lymph node involvement and LRR. Results: Among 1558 patients undergoing surgery during the time interval, 236 were evaluable for risk of regional lymph node involvement and 234 for LRR risk. As a continuous variable, SUVmax was not associated with a higher risk of regional lymph node involvement on univariate (HR 0.99, p = 0.93) or multivariate (HR 0.95, p = 0.06) analysis. Similarly, SUVmax as
S581
I. J. Radiation Oncology d Biology d Physics
S582
Volume 81, Number 2, Supplement, 2011
a continuous variable was not associated with LRR on univariate (HR 1.03, p = 0.12) or multivariate (HR 1.02, p = 0.55) analysis. When using median SUVmax as a threshold, SUVmax was not predictive for regional lymph node involvement on univariate analysis (p = 0.39). Although SUVmax . 9.7 was associated with higher LRR risk on univariate analysis (20% vs 11%, p = 0.047), it was not significant on multivariate analysis (HR 0.60, p = 0.29). Conclusions: On multivariate analysis, SUVmax of the primary tumor did not predict for regional lymph node involvement or LRR in resected NSCLC. Author Disclosure: J.M. Pepek: None. J.P. Chino: None. K.A. Higgins: None. D.S. Yoo: None. C.R. Kelsey: None.
2774
Demography and Survival of Lung Cancer Patients in Tobacco Predominant Eastern North Carolina: A Single Institution Study
T. Biswas1, S. Hudson1, T. K. Podder1, M. Brinson1, J. Rosenman2, J. T. Efird1 1 Brody School of Medicine - East Carolina University, Greenville, NC, 2University of North Carolina at Chapel Hill, Chapel Hill, NC
Purpose/Objective(s): Lung Cancer is the most commonly diagnosed cancer and leading cause of death in US. It is known that lung cancer incidence and mortality are higher in African Americans (AAs) compared to whites. In the Eastern North Carolina, there is higher percentage than national average (30.2% vs 12.4%) of AA population and higher incidence of lung cancer in this region. This retrospective study examines the demography and survival of lung cancer patients diagnosed and treated in a single institution. Materials/Methods: The study population consists of 2384 patients diagnosed with lung cancer between 2001 and 2010 at the Leo Jenkins Cancer Center. AAs and whites were compared by age, sex, race, stage, histology, smoking history and insurance information using chi-square analyses. Patient survival was modeled using Cox proportional hazards regression (SAS version 9.2). Results: Of the 2384 patients, 70% (n = 1658) were whites and 30% were AAs. 635 patients (26%) with Stage I, 247 (10%) with Stage II, 613 (27%) with Stage III and 889 (37%) with Stage IV disease were diagnosed. Squamous cell carcinoma (31%) and adenocarcinoma (30%) were the most common histology followed by small cell lung cancer (SCLC) (11%), bronchoalveolar (2%) and large cell/ neuroendocrine tumor (3%). 21% had a diagnosis of non-small cell lung cancer (NSCLC) not otherwise specified (NOS) and 2% had other subtypes. The proportion of AAs and whites differed for age (p\0.0001), gender (p\ 0.0001), histology (p = 0.0002), stage (p\0.0001), smoking history at diagnosis (p = 0.073) and insurance (p = 0.0001). However, overall survival was approximately equal between AAs and whites (HR = 1.1). On univariate analysis, patients aged .70 (p\0.0001) and 51 - 70 (p\0.0001) died sooner than those #50 years old. Compared with squamous cell, SCLC had the worst survival (HR = 2.0, 95%CI1.7 - 2.3). No survival difference was observed between adenocarcinoma and squamous histology (HR = 1.04). Surprisingly, patients with diagnosis of NSCLC NOS had poor outcome (HR = 1.8, 95%CI1.6 - 2.1). Interestingly, privately insured patients survived longer than those with Medicare [with (p\0.0001) or without (p = 0.0009) supplemental insurance], Medicaid (p = 0.0009), or no insurance (p\0.0001). The survival disadvantage for Medicaid (p = 0.0008) and no insurance (0.0053) persisted after controlling for age, stage, and morphology. Neither race, gender nor smoking history (prior or current) had any impact on patient survival (univariate and multivariate analysis). Conclusions: This is one of the largest lung cancer patient populations from a single institution showing demographic differences between AAs and whites with similar survival outcome. Planned analyses will compare incidence/ prevalence rate and survival with the SEER registry. Author Disclosure: T. Biswas: None. S. Hudson: None. T.K. Podder: None. M. Brinson: None. J. Rosenman: None. J.T. Efird: None.
2775
30 Gy in a Single Fraction: Early Experience in Lung Radiosurgery (SRS) at Cleveland Clinic
G. M. Videtic, K. Stephans, N. Woody, C. Reddy, A. Magnelli, T. Djemil Cleveland Clinic, Cleveland, OH Purpose/Objective(s): Patients with medically inoperable early stage NSCLC are managed with Stereotactic Body Radiotherapy (SBRT) at our institution. After joining a stereotactic radiosurgery (SRS) prospective trial in 2009 testing 30 Gy in a single fraction, we have begun to offer this approach to selected patients off protocol, typically with small peripheral lesions, but treated them per protocol parameters. We now report preliminary outcomes for our cohort of patients treated using SRS. Materials/Methods: Patients considered for SRS had to have a node negative, peripherally located lung cancer measuring #5cm. All radiotherapy planning was modeled after the criteria provided by the RTOG 0236 protocol. All patients were treated on a Novalis/BrainLAB system using Exactrac for IGRT and with the same methodology for tumor motion control involving Bodyfix for immobilization along with abdominal compression. Results: 32 lesions in 31 consecutive patients (one with synchronous primaries) have been treated between 11/2009 and 12/2010; 10 (31.3%) patients were on the protocol. Median age was 76 (range 52 - 91), median KPS was 80 (range 50 100), median BMI was 25.5 (range 12.1 - 48.8), 72% were male, median FEV1 and DLCO as % predicted were 55.5 and 48.5, respectively, with 58% of pts inoperable due to pulmonary comorbidities. Tumor characteristics included: median maximum diameter of 1.8 cm (range 0.9 - 4.1), 93.8% were Stage Ia, median PET SUVmax of 7.4 (range 1.8 26.2), 66% with tissue diagnosis (non-small cell lung cancer).All patients are alive at analysis, local control is 100%.There have been 2 (6.5%) regional nodal and 2 (6.5%) distant failures. Median distant metastasis-disease free survival is 10.7 months. No significant changes in FEV1 post-SRS have been noted. There have been no grade 3 toxicities and one grade 2 chest wall toxicity.
2772
Withholding Stereotactic Radiotherapy in Elderly Patients with Stage I Non-small Cell Lung Cancer and Co-existing COPD is not Justified: Outcomes of a Markov Model Analysis
A. V. Louie1, G. Rodrigues1, M. Hannouf1, F. Lagerwaard2, D. Palma1, G. S. Zaric1, C. J. A. Haasbeek2, S. Senan2 1
University of Western Ontario, London, ON, Canada, 2VU University Medical Center, Amsterdam, Netherlands
Purpose/Objective(s): To compare outcomes in elderly COPD patients with Stage I non-small cell lung cancer (NSCLC) treated with either stereotactic body radiation therapy (SBRT) or best supportive care (BSC). While high cure rates with low toxicity have been reported after SBRT in elderly patients, severe COPD is often cited as a reason for withholding SBRT from these patients. Materials/Methods: A Markov model was constructed to simulate the quality adjusted life expectancy (QALE) and overall survival in patients $75 years undergoing either SBRT or BSC for a 5-year timeframe. For SBRT, the rates of local, regional and distant recurrences were obtained from 247 patients entered into a prospective cohort at the VUMC, Amsterdam. Recurrences were converted into monthly transition probabilities and stratified into 4 groups according to T stage and COPD GOLD score. The 4 patient groups were: I (T1, GOLD I-II), II (T2, GOLD I-II), III (T1, GOLD III-IV), and IV (T2 GOLD III-IV). For untreated patients, overall survival by T stage was modeled according to 1,432 untreated patients from the California Cancer Registry. Markov state utilities consistent with the four stages of the AJCC staging system and COPD status based on GOLD score, were extracted and adapted from the literature. Results: Our Markov model showed a close correlation with overall survival data for all 4 groups treated with SBRT, with differences at 5 years ranging from 0.1% to 1.5%. For untreated patients, the differences were 0.1% for T1 patients and 2.2% for T2 patients at 5 years. After SBRT, 5-year overall survival ranged from 6.8% to 47.2% and QALE ranging from 14.9 to 27.4 quality adjusted life months (QALMs). 5-year overall survival for untreated T1 and T2 patients was 9.0% and 2.8%, and 10.1 and 6.1 QALMs, respectively. Outcomes were not sensitive to the quality of life post-SBRT or the disutility of disease progression in untreated patients. The relative benefit of SBRT over BSC appears to be least for group IV patients. Conclusions: In elderly patients with COPD, our Markov model predicts superior overall and QALE at 5 years after SBRT when compared to no treatment. Advanced age, COPD, and tumor size should not preclude such patients from curative SBRT. Author Disclosure: A.V. Louie: None. G. Rodrigues: None. M. Hannouf: None. F. Lagerwaard: None. D. Palma: None. G.S. Zaric: None. C.J.A. Haasbeek: None. S. Senan: D. Speakers Bureau/Honoraria; Varian Medical Systems Inc.
2773
Does SUVmax of the Primary Tumor Predict Regional Lymph Node Involvement or Local/Regional Recurrence in Resected Non-small Cell Lung Cancer?
J. M. Pepek, J. P. Chino, K. A. Higgins, D. S. Yoo, C. R. Kelsey Duke University Medical Center, Durham, NC Purpose/Objective(s): 18-fluorine fluorodeoxyglucose positron emission tomography (PET) is increasingly utilized to stage non-small cell lung cancer (NSCLC). Several studies have shown that the maximum standardized uptake value (SUVmax) of the primary tumor is prognostic for overall survival, though this remains controversial. This analysis evaluated whether SUVmax of the primary tumor independently predicts for regional lymph node involvement (pN1-N2) and for subsequent local/regional recurrence (LRR). Materials/Methods: All patients with resected Stage I-IIIA NSCLC between 1995 and 2008 who did not receive any preoperative therapy and had a preoperative PET with a reported SUVmax of the primary tumor were evaluated from a single institution database. Those without any lymph node sampling were excluded when evaluating factors associated with regional lymph node involvement. Patients who received postoperative radiation therapy or had positive surgical margins were excluded when evaluating factors associated with LRR. Disease recurrence at the surgical margin or within ipsilateral hilar and/or mediastinal lymph nodes was considered a LRR. Disease recurrence in the contralateral hilum, supraclavicular fossae, ipsilateral lung parenchyma, or elsewhere was defined as a distant metastasis. Univariate and multivariate analyses, using the median SUVmax of our cohort as a threshold (SUVmax 9.7) and SUVmax as a continuous variable, were performed to evaluate independent risk factors of regional lymph node involvement and LRR. Results: Among 1558 patients undergoing surgery during the time interval, 236 were evaluable for risk of regional lymph node involvement and 234 for LRR risk. As a continuous variable, SUVmax was not associated with a higher risk of regional lymph node involvement on univariate (HR 0.99, p = 0.93) or multivariate (HR 0.95, p = 0.06) analysis. Similarly, SUVmax as
S581
I. J. Radiation Oncology d Biology d Physics
S582
Volume 81, Number 2, Supplement, 2011
a continuous variable was not associated with LRR on univariate (HR 1.03, p = 0.12) or multivariate (HR 1.02, p = 0.55) analysis. When using median SUVmax as a threshold, SUVmax was not predictive for regional lymph node involvement on univariate analysis (p = 0.39). Although SUVmax . 9.7 was associated with higher LRR risk on univariate analysis (20% vs 11%, p = 0.047), it was not significant on multivariate analysis (HR 0.60, p = 0.29). Conclusions: On multivariate analysis, SUVmax of the primary tumor did not predict for regional lymph node involvement or LRR in resected NSCLC. Author Disclosure: J.M. Pepek: None. J.P. Chino: None. K.A. Higgins: None. D.S. Yoo: None. C.R. Kelsey: None.
2774
Demography and Survival of Lung Cancer Patients in Tobacco Predominant Eastern North Carolina: A Single Institution Study
T. Biswas1, S. Hudson1, T. K. Podder1, M. Brinson1, J. Rosenman2, J. T. Efird1 1 Brody School of Medicine - East Carolina University, Greenville, NC, 2University of North Carolina at Chapel Hill, Chapel Hill, NC
Purpose/Objective(s): Lung Cancer is the most commonly diagnosed cancer and leading cause of death in US. It is known that lung cancer incidence and mortality are higher in African Americans (AAs) compared to whites. In the Eastern North Carolina, there is higher percentage than national average (30.2% vs 12.4%) of AA population and higher incidence of lung cancer in this region. This retrospective study examines the demography and survival of lung cancer patients diagnosed and treated in a single institution. Materials/Methods: The study population consists of 2384 patients diagnosed with lung cancer between 2001 and 2010 at the Leo Jenkins Cancer Center. AAs and whites were compared by age, sex, race, stage, histology, smoking history and insurance information using chi-square analyses. Patient survival was modeled using Cox proportional hazards regression (SAS version 9.2). Results: Of the 2384 patients, 70% (n = 1658) were whites and 30% were AAs. 635 patients (26%) with Stage I, 247 (10%) with Stage II, 613 (27%) with Stage III and 889 (37%) with Stage IV disease were diagnosed. Squamous cell carcinoma (31%) and adenocarcinoma (30%) were the most common histology followed by small cell lung cancer (SCLC) (11%), bronchoalveolar (2%) and large cell/ neuroendocrine tumor (3%). 21% had a diagnosis of non-small cell lung cancer (NSCLC) not otherwise specified (NOS) and 2% had other subtypes. The proportion of AAs and whites differed for age (p\0.0001), gender (p\ 0.0001), histology (p = 0.0002), stage (p\0.0001), smoking history at diagnosis (p = 0.073) and insurance (p = 0.0001). However, overall survival was approximately equal between AAs and whites (HR = 1.1). On univariate analysis, patients aged .70 (p\0.0001) and 51 - 70 (p\0.0001) died sooner than those #50 years old. Compared with squamous cell, SCLC had the worst survival (HR = 2.0, 95%CI1.7 - 2.3). No survival difference was observed between adenocarcinoma and squamous histology (HR = 1.04). Surprisingly, patients with diagnosis of NSCLC NOS had poor outcome (HR = 1.8, 95%CI1.6 - 2.1). Interestingly, privately insured patients survived longer than those with Medicare [with (p\0.0001) or without (p = 0.0009) supplemental insurance], Medicaid (p = 0.0009), or no insurance (p\0.0001). The survival disadvantage for Medicaid (p = 0.0008) and no insurance (0.0053) persisted after controlling for age, stage, and morphology. Neither race, gender nor smoking history (prior or current) had any impact on patient survival (univariate and multivariate analysis). Conclusions: This is one of the largest lung cancer patient populations from a single institution showing demographic differences between AAs and whites with similar survival outcome. Planned analyses will compare incidence/ prevalence rate and survival with the SEER registry. Author Disclosure: T. Biswas: None. S. Hudson: None. T.K. Podder: None. M. Brinson: None. J. Rosenman: None. J.T. Efird: None.
2775
30 Gy in a Single Fraction: Early Experience in Lung Radiosurgery (SRS) at Cleveland Clinic
G. M. Videtic, K. Stephans, N. Woody, C. Reddy, A. Magnelli, T. Djemil Cleveland Clinic, Cleveland, OH Purpose/Objective(s): Patients with medically inoperable early stage NSCLC are managed with Stereotactic Body Radiotherapy (SBRT) at our institution. After joining a stereotactic radiosurgery (SRS) prospective trial in 2009 testing 30 Gy in a single fraction, we have begun to offer this approach to selected patients off protocol, typically with small peripheral lesions, but treated them per protocol parameters. We now report preliminary outcomes for our cohort of patients treated using SRS. Materials/Methods: Patients considered for SRS had to have a node negative, peripherally located lung cancer measuring #5cm. All radiotherapy planning was modeled after the criteria provided by the RTOG 0236 protocol. All patients were treated on a Novalis/BrainLAB system using Exactrac for IGRT and with the same methodology for tumor motion control involving Bodyfix for immobilization along with abdominal compression. Results: 32 lesions in 31 consecutive patients (one with synchronous primaries) have been treated between 11/2009 and 12/2010; 10 (31.3%) patients were on the protocol. Median age was 76 (range 52 - 91), median KPS was 80 (range 50 100), median BMI was 25.5 (range 12.1 - 48.8), 72% were male, median FEV1 and DLCO as % predicted were 55.5 and 48.5, respectively, with 58% of pts inoperable due to pulmonary comorbidities. Tumor characteristics included: median maximum diameter of 1.8 cm (range 0.9 - 4.1), 93.8% were Stage Ia, median PET SUVmax of 7.4 (range 1.8 26.2), 66% with tissue diagnosis (non-small cell lung cancer).All patients are alive at analysis, local control is 100%.There have been 2 (6.5%) regional nodal and 2 (6.5%) distant failures. Median distant metastasis-disease free survival is 10.7 months. No significant changes in FEV1 post-SRS have been noted. There have been no grade 3 toxicities and one grade 2 chest wall toxicity.