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EP-1252: Preliminary outcomes and toxicity in anal cancer treated with definitive VMAT chemoradiotherapy
ESTRO 33, 2014 Survival was 66% and 28% respectively, with a median survival time of 15.3 months. Conclusions: The combination of cetuximab and gemcitabine with concurrent radiation therapy provides a feasible and well tolerated treatment for locally advanced pancreatic cancer. Patients’ selection is crucial in order to treat patients appropriately. EP-1252 Preliminary outcomes and toxicity in anal cancer treated with definitive VMAT chemoradiotherapy E. Ciurlia1, F. Valvo1, A. Cavallo2, B. Avuzzi1, C. Chiruzzi1, M.C. De Santis1, S. Fantini1, M. Franceschini1, E. Pignoli2, R. Valdagni1 1 Fondazione IRCCS Istituto Nazionale dei Tumori, Radiation Oncology 1, Milan, Italy 2 Fondazione IRCCS Istituto Nazionale dei Tumori, Medical Physics, Milan, Italy Purpose/Objective: To investigate the role of Volumetric Modulated Arc Therapy ( VMAT) in anal cancer treatment in terms of clinical outcomes and toxicity. Materials and Methods: Since January 2010 twenty-five consecutive patients (median age 68, range 47 – 88; M/F = 3/22) were treated in our Institution. To patients with stage T1N0 ( n= 4) were prescribed 36 – 39 Gy to pelvis and inguinal nodes ( 1.8 Gy/fraction) followed by a boost of 20 Gy ( 2 Gy/fraction) on anal canal; for any other stage ( n=18) the prescription was 45 Gy on pelvis and inguinal nodes ( 1.8 Gy/fraction) and 15 Gy ( 2.1 Gy/fraction) on anal canal. In 22 patients radiotherapy was concomitant to chemotherapy (2 cycles of CDDP-5FU in 20 patients; daily capecitabine in 2 patients). In three patients unfit for chemotherapy, radiotherapy was delivered to a total dose of 65 Gy on anal canal, 52 Gy on positive lymph nodes and 48 Gy on pelvis and inguinal nodes in 24 fraction with concomitant boost. CTV was defined according to RTOG. PTV was generated adding 8 – 10 mm to CTV. CBCTs were performed before the first three fractions and then weekly. Image registration between CBCT and planning CT was based on bony anatomy. Results: Median overall treatment time was 46 days (range 38 – 61) with a mean interruption time of 3 days ( range 0 – 11). No G4 toxicity was found. G3 acute skin toxicity in inguinal and perineal skin was detected in 2 and 22 patients ( 8% and 88%) respectively. G3 gastrointestinal and genitourinary toxicity were in turn observed in 3 ( 12%) and 2 patients ( 8%). At the analysis time (median follow up of 14 months), 23 patients show no evidence of disease ( 92%) and two died of other diseases (one had achieved partial response) resulting in 100% disease specific overall survival. Conclusions: Although preliminary and with limited follow up, our results show that VMAT radiotherapy in anal cancer allows a high rate of local control, with low GI, GU and inguinal skin acute toxicity. However, the decrease of toxicity cannot be extended to perineal skin. More data and longer follow up are necessary to confirm clinical outcomes and late toxicity. EP-1253 Prognostic factors in lymph node positive rectal cancer after surgery following neoadjuvant chemoradiotherapy T.R. Koo1, J.S. Kim1, S.B. Kang2 1 Seoul National University College of Medicine, Department of Radiation Oncology, Seoul, Korea Republic of 2 Seoul National University College of Medicine, Department of Surgery, Seoul, Korea Republic of Purpose/Objective: This study is aimed at evaluating prognostic factors in lymph node (LN) positive rectal cancer patients who underwent neoadjuvant chemoradiotherapy (NCRT) and curative resection. Materials and Methods: Between April 2004 and April 2011, 216 patients with rectal cancer underwent NCRT. Of these, 53 patients were enrolled, who were diagnosed LN positive after surgery. Among many known prognostic factors, lymph node ratio (LNR) was specifically included in this study whether it has prognostic meaning or not. By using a maximal chi-square method, the cut-off value of LNR was selected as 0.12. Patients were divided into two groups: LNR ≤ 0.12 (n = 28) and > 0.12 (n = 25). The primary endpoint was disease-free survival (DFS). Results: The median follow-up time was 44.2 months (19.4 – 108.5 months) for entire patients, and 55.7 months (24.9–108.5 months) for surviving patients. The 3-year locoregional recurrence-free survival, DFS and overall survival rates were 100%, 66.6% and 82.9%, respectively. One local failure (at 57.5 months) and one regional failure (at 38.6 months) were noted. Median number of harvested LN was 21 (6 – 50), and median
S73 LNR was 0.12 (range, 0.02 – 0.44). In the univariate analysis, high LNR (p = 0.001), lymphovascular invasion (p = 0.010), and perineural invasion (p = 0.002) were associated with worse DFS. Factors showing a trend of worse DFS was ypN2-3 stage vs. ypN1 (p = 0.088). Close circumferential resection margin (≤ 2mm) and tumor regression grade had no statistically significant association with DFS. Multivariate analysis was performed for DFS including aforementioned factors and other known prognostic factors of rectal cancer: ypT stage, tumor differentiation, number of harvested LN, and CEA level (before and after NCRT, and postoperatively). Finally, LNR (p = 0.015; hazard ratio [HR] = 3.677) and perineural invasion (p = 0.038; HR = 2.675) were identified as significant prognostic factors of DFS. For the subgroup analysis, patients with ypN1 were separated into two groups, LNR ≤ 0.12 (n = 27) and LNR > 0.12 (n = 10). In ypN1 patients, there was significant difference in DFS (p = 0.004) according to LNR. Interestingly, between patients with ypN1 and LNR >0.12 and those with ypN2-3, there was no significant difference in DFS (p = 0.613). Conclusions: LNR could be considered as an important prognostic factor in rectal cancer patients who have had positive LN after curative resection following NCRT. In patients with ypN1 rectal cancer, LNR could be used to select a high risk group for postoperative adjuvant treatment. EP-1254 Achieving durable local control without surgery in unresectable, metastatic rectal cancer S. Chander1, P. Cooray2, J. McKendrick2, S.W. Wong2, C. Ngan3, M. Michael4, M. Steel5, S. Ngan1 1 Peter Mac Callum Cancer Centre, Division of Radiation Oncology and Cancer Imaging, Melbourne, Australia 2 Box Hill Hospital, Medical Oncology, Melbourne, Australia 3 University of Melbourne, Faculty of Medicine, Melbourne, Australia 4 Peter MacCallum Cancer Centre, Medical Oncology, Melbourne, Australia 5 Box Hill Hospital, Department Of Surgery, Melbourne, Australia Purpose/Objective: In metastatic, incurable rectal cancer, maintaining quality of life is of paramount importance. The aim of this study is to review our efficacy in achieving local control while avoiding pelvic surgery and potential colostomy, in patients presenting with untreated simultaneous symptomatic primary and metastatic rectal cancer. We used a new treatment regimen delivering intensive chemotherapy and radical radiotherapy in a synchronised manner to achieve optimum systemic and local control concurrently in these patients. Materials and Methods: Patients treated on this new metastatic rectal cancer protocol with a regimen including a split course of pelvic radiation with inter-digitating FOLFOX chemotherapy were included in this study. Over 12 weeks, patients received 3 courses of FOLFOX and pelvic radiation with a dose of 50.4 Gy in 28 fractions, split in two lots of 25.2Gy each, with concurrent oxaliplatin and 5-FU. Results: Thirty-eight patients were treated with the inter-digitating protocol in this study. The mean age was 63 (range 33-84) years, 63% were male. Liver, lung, extra-pelvic nodes and other metastases were present in 74%, 26%, 13% and 11% of patients, respectively. Thirty – Seven percent (37%) of patients had more than one site of metastatic disease. Assessment with PET scan was performed 4 weeks after treatment. A total of 18 patients underwent pelvic surgery to resect the primary after the chemo-radiation, since they had potentially curable disease after this protocol treatment. This was possible due to either a complete response of metastatic disease on PET scan (6pts), resectable liver disease (8pts) or other oligometastatic sites resected (3). One patient had a limited local recurrence removed after 4 years. Seventeen of the remaining 20 patients (85%) with persistent unresectable metastatic disease did not require pelvic surgery. Three patients had a colostomy for palliation, 1 prior to chemo RT for obstruction and another who had peri anal sinuses and fistula. Therefore there was only one patient in this whole cohort of 38 who needed a palliative colostomy for progressive disease despite chemoRT. Median survival for the whole group was 21.5 months. For surviving patients (n=15), median follow-up was 30 (range 18-57) months. Conclusions: This regimen provides a durable local control, without compromising systemic therapy in patients presenting with rectal cancer and synchronous metastasis. Pelvic surgery and colostomy can be avoided and reserved only for those patients with symptomatic progressive disease in the pelvis, thus maintaining quality of life for these unfortunate patients who will succumb to their incurable disease.
S73 LNR was 0.12 (range, 0.02 – 0.44). In the univariate analysis, high LNR (p = 0.001), lymphovascular invasion (p = 0.010), and perineural invasion (p = 0.002) were associated with worse DFS. Factors showing a trend of worse DFS was ypN2-3 stage vs. ypN1 (p = 0.088). Close circumferential resection margin (≤ 2mm) and tumor regression grade had no statistically significant association with DFS. Multivariate analysis was performed for DFS including aforementioned factors and other known prognostic factors of rectal cancer: ypT stage, tumor differentiation, number of harvested LN, and CEA level (before and after NCRT, and postoperatively). Finally, LNR (p = 0.015; hazard ratio [HR] = 3.677) and perineural invasion (p = 0.038; HR = 2.675) were identified as significant prognostic factors of DFS. For the subgroup analysis, patients with ypN1 were separated into two groups, LNR ≤ 0.12 (n = 27) and LNR > 0.12 (n = 10). In ypN1 patients, there was significant difference in DFS (p = 0.004) according to LNR. Interestingly, between patients with ypN1 and LNR >0.12 and those with ypN2-3, there was no significant difference in DFS (p = 0.613). Conclusions: LNR could be considered as an important prognostic factor in rectal cancer patients who have had positive LN after curative resection following NCRT. In patients with ypN1 rectal cancer, LNR could be used to select a high risk group for postoperative adjuvant treatment. EP-1254 Achieving durable local control without surgery in unresectable, metastatic rectal cancer S. Chander1, P. Cooray2, J. McKendrick2, S.W. Wong2, C. Ngan3, M. Michael4, M. Steel5, S. Ngan1 1 Peter Mac Callum Cancer Centre, Division of Radiation Oncology and Cancer Imaging, Melbourne, Australia 2 Box Hill Hospital, Medical Oncology, Melbourne, Australia 3 University of Melbourne, Faculty of Medicine, Melbourne, Australia 4 Peter MacCallum Cancer Centre, Medical Oncology, Melbourne, Australia 5 Box Hill Hospital, Department Of Surgery, Melbourne, Australia Purpose/Objective: In metastatic, incurable rectal cancer, maintaining quality of life is of paramount importance. The aim of this study is to review our efficacy in achieving local control while avoiding pelvic surgery and potential colostomy, in patients presenting with untreated simultaneous symptomatic primary and metastatic rectal cancer. We used a new treatment regimen delivering intensive chemotherapy and radical radiotherapy in a synchronised manner to achieve optimum systemic and local control concurrently in these patients. Materials and Methods: Patients treated on this new metastatic rectal cancer protocol with a regimen including a split course of pelvic radiation with inter-digitating FOLFOX chemotherapy were included in this study. Over 12 weeks, patients received 3 courses of FOLFOX and pelvic radiation with a dose of 50.4 Gy in 28 fractions, split in two lots of 25.2Gy each, with concurrent oxaliplatin and 5-FU. Results: Thirty-eight patients were treated with the inter-digitating protocol in this study. The mean age was 63 (range 33-84) years, 63% were male. Liver, lung, extra-pelvic nodes and other metastases were present in 74%, 26%, 13% and 11% of patients, respectively. Thirty – Seven percent (37%) of patients had more than one site of metastatic disease. Assessment with PET scan was performed 4 weeks after treatment. A total of 18 patients underwent pelvic surgery to resect the primary after the chemo-radiation, since they had potentially curable disease after this protocol treatment. This was possible due to either a complete response of metastatic disease on PET scan (6pts), resectable liver disease (8pts) or other oligometastatic sites resected (3). One patient had a limited local recurrence removed after 4 years. Seventeen of the remaining 20 patients (85%) with persistent unresectable metastatic disease did not require pelvic surgery. Three patients had a colostomy for palliation, 1 prior to chemo RT for obstruction and another who had peri anal sinuses and fistula. Therefore there was only one patient in this whole cohort of 38 who needed a palliative colostomy for progressive disease despite chemoRT. Median survival for the whole group was 21.5 months. For surviving patients (n=15), median follow-up was 30 (range 18-57) months. Conclusions: This regimen provides a durable local control, without compromising systemic therapy in patients presenting with rectal cancer and synchronous metastasis. Pelvic surgery and colostomy can be avoided and reserved only for those patients with symptomatic progressive disease in the pelvis, thus maintaining quality of life for these unfortunate patients who will succumb to their incurable disease.