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CT for Esophageal Cancer GTV Delineation for Radiation Therapy Treatment Planning
Poster Viewing Session E177
Volume 93 Number 3S Supplement 2015
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Fiducials Versus F-FDG PET/CT for Esophageal Cancer GTV Delineation for Radiation Therapy Treatment Planning K. Latifi,1,2 J.A. Oliver,1,2 J. Montilla-Soler,1 J. Klapman,3 G.C. Dhadham,3 C. Harris,3 K. Emanuel,4 J. Werner,4 J.M. Frakes,1 R. Shridhar,5 T.J. Dilling,1 G.G. Zhang,1,2 E.G. Moros,1,2 and S.E. Hoffe1; 1 H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 2 University of South Florida, Tampa, FL, 3H. Lee Moffitt Cancer Center and Research Institute, Gastrointestinal Tumor Program, Tampa, FL, 4H. Lee Moffitt Cancer Center and Research Institute, Department of Diagnostic Imaging, Tampa, FL, 5Florida Hospital Cancer Institute, Orlando, FL Purpose/Objective(s): 3D 18F-FDG PET/CT is obtained routinely for the initial staging of esophageal cancer and has been shown in several sites to alter the GTV delineation. The role of 3D PET/CT in esophageal tumors that move with respiration and have the potential for significant mucosal inflammation is unclear. Our group has previously reported the stability data of esophageal fiducial markers endoscopically implanted under ultrasound guidance within 1 cm from the superior and inferior edges of the tumor. The correlation between gross tumor volumes derived from 3D PET/CT vs. endoscopically placed fiducial markers has not yet been reported. Materials/Methods: This was a retrospective, IRB approved analysis of 20 esophageal patients who had fiducials implanted followed by PET/ CT. Images were imported into an image analysis software system for measurements. A point was placed to mark the centroid of each fiducial. For each centroid we determined the absolute and relative PET/CT uptake (SUV) that defined the metabolic tumor volume (MTV) boundary where the centroid was located. We also measured the distance between each centroid and the MTV border defined by an SUV of 2.5 contour. Results: The inferior fiducial centroid corresponded to a median absolute SUV of 2.9 (2.1 16.5), or 30% (15% 83%) relative uptake. The superior fiducial centroid corresponded to a median absolute SUV of 7.2 (2.1 26.2), or 81% (16% 99%) relative uptake. The median distance between the inferior fiducial centroid and the PET/CT contour for 2.5 SUV was 0.0 cm (-1.6 2.8 cm). The median distance between the superior fiducial centroid and the 2.5 SUV contour was 1.5 cm (-0.3 6.9 cm). Conclusion: There was a robust correlation between the inferior fiducial location and the border of the MTV; i.e., the absolute and relative SUV values were reasonably close to commonly used values such as 2.5 and 40% of SUVmax. It is unclear, however, the etiology of the discordance superiorly, with the PET/CT showing high uptake at and above the endoscopically placed marker, potentially representing benign secondary esophagitis such as in the setting of luminal obstruction, the presence of malignant nodes, inflammation caused by the technical aspects of the fiducial placement itself, or potential submucosal disease. According to these findings, the incorporation of a fiducial marker inferiorly into the routine management of locally advanced esophageal cancer may offer an accurate target volume delineation when compared with 3D PET/CT. The factors confounding FDG uptake superiorly need further investigation to optimize GTV delineation. Author Disclosure: K. Latifi: None. J.A. Oliver: None. J. MontillaSoler: None. J. Klapman: None. G.C. Dhadham: None. C. Harris: None. K. Emanuel: None. J. Werner: None. J.M. Frakes: None. R.
Shridhar: None. T.J. Dilling: None. G.G. Zhang: None. E.G. Moros: None. S.E. Hoffe: None.
2450 Adjuvant Chemoradiation Therapy in Cholangiocarcinoma: A SingleInstitution Experience L.M. Rosati, V. Charu, A. Hacker-Prietz, PA-C, L. Zheng, D.P. Cosgrove, T.M. Pawlik, and J.M. Herman; Johns Hopkins University School of Medicine, Baltimore, MD Purpose/Objective(s): The role of adjuvant therapy in cholangiocarcinoma (CC) is largely unclear. This retrospective study was conducted to evaluate our institutional experience with adjuvant chemoradiation therapy (CRT) in intrahepatic (IH) and extrahepatic (EH) CC. Materials/Methods: The charts of 28 patients with IHCC or EHCC who received intensity-modulated radiation therapy with concurrent capecitabine chemotherapy from 2010 to 2014 at Johns Hopkins Hospital were reviewed. Survival estimates were calculated using Kaplan-Meier statistics. Results: Median time of follow-up was 16.1 months (months) from the end of CRT (range, 0.3-45.1). The median age at diagnosis was 62.4 years (range, 47-81) and 75% of patients were male. The majority (67.9%) of patients were diagnosed with EHCC whereas 32.1% had IHCC. Twentysix (93%) of the 28 patients were resected at our institution. Median tumor size was 1.9 cm (range, 0.8-10). The rate of margin-negative (R0) resection was 64%, and 30% of the 23 patients who underwent lymph node dissection achieved a node-negative resection. Twenty (71%) patients received upfront chemotherapy followed by CRT, 70% of which received 4 cycles of gemcitabine and capecitabine as administered in the Southwest Oncology Group (SWOG) S0809 phase II trial, whereas 29% of patients received upfront concurrent CRT. The median cumulative dose of RT was 52.5 Gray ([Gy] range, 30-54) in 2.1-Gy fractions (range, 1.82.2). Median overall survival (mOS) was 47.8 months (95% confidence interval [CI], 17.4-78.1). Rates of 1-year and 4-year survival were 92% and 45%, respectively. Patients with EHCC survived a median of 47.8 months in comparison with 33.5 months in IHCC (pZNS). Furthermore, a R0 resection (48.2 vs. 31.2 months, pZNS), lymph node dissection (47.8 vs. 31.2 months, pZNS) and upfront chemotherapy followed by CRT (50.8 vs. 31.2 months, pZNS), as opposed to upfront CRT, were associated with superior survival. Median progression-free survival was 30.9 months (95% CI, 10.7-51.2). In the 12 patients (43%) who were shown to have progressed on imaging, 7 (58%) progressed at a distant site first, 2 (17%) at a local site, and 3 (25%) experienced synchronous local and distant progression. Multivariate analyses revealed that the hazard of death among diabetic patients is 8.29 times that of non-diabetic patients (95% CI, 1.8-37.8) and that among patients undergoing upfront CRT is 4.77 times that of patients undergoing upfront chemotherapy prior to CRT (95% CI, 1.1-20.4). Conclusion: Despite the small numbers, this study suggests that adjuvant therapy may play a significant role in optimizing clinical outcomes in CC. Furthermore, our results support the sequence of therapy in EHCC prospectively evaluated in SWOG 0809. Prospective investigation of adjuvant therapy in IHCC is necessary. Author Disclosure: L.M. Rosati: None. V. Charu: None. A. HackerPrietz, PA-C: None. L. Zheng: None. D.P. Cosgrove: None. T.M. Pawlik: None. J.M. Herman: None.
Volume 93 Number 3S Supplement 2015
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Fiducials Versus F-FDG PET/CT for Esophageal Cancer GTV Delineation for Radiation Therapy Treatment Planning K. Latifi,1,2 J.A. Oliver,1,2 J. Montilla-Soler,1 J. Klapman,3 G.C. Dhadham,3 C. Harris,3 K. Emanuel,4 J. Werner,4 J.M. Frakes,1 R. Shridhar,5 T.J. Dilling,1 G.G. Zhang,1,2 E.G. Moros,1,2 and S.E. Hoffe1; 1 H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 2 University of South Florida, Tampa, FL, 3H. Lee Moffitt Cancer Center and Research Institute, Gastrointestinal Tumor Program, Tampa, FL, 4H. Lee Moffitt Cancer Center and Research Institute, Department of Diagnostic Imaging, Tampa, FL, 5Florida Hospital Cancer Institute, Orlando, FL Purpose/Objective(s): 3D 18F-FDG PET/CT is obtained routinely for the initial staging of esophageal cancer and has been shown in several sites to alter the GTV delineation. The role of 3D PET/CT in esophageal tumors that move with respiration and have the potential for significant mucosal inflammation is unclear. Our group has previously reported the stability data of esophageal fiducial markers endoscopically implanted under ultrasound guidance within 1 cm from the superior and inferior edges of the tumor. The correlation between gross tumor volumes derived from 3D PET/CT vs. endoscopically placed fiducial markers has not yet been reported. Materials/Methods: This was a retrospective, IRB approved analysis of 20 esophageal patients who had fiducials implanted followed by PET/ CT. Images were imported into an image analysis software system for measurements. A point was placed to mark the centroid of each fiducial. For each centroid we determined the absolute and relative PET/CT uptake (SUV) that defined the metabolic tumor volume (MTV) boundary where the centroid was located. We also measured the distance between each centroid and the MTV border defined by an SUV of 2.5 contour. Results: The inferior fiducial centroid corresponded to a median absolute SUV of 2.9 (2.1 16.5), or 30% (15% 83%) relative uptake. The superior fiducial centroid corresponded to a median absolute SUV of 7.2 (2.1 26.2), or 81% (16% 99%) relative uptake. The median distance between the inferior fiducial centroid and the PET/CT contour for 2.5 SUV was 0.0 cm (-1.6 2.8 cm). The median distance between the superior fiducial centroid and the 2.5 SUV contour was 1.5 cm (-0.3 6.9 cm). Conclusion: There was a robust correlation between the inferior fiducial location and the border of the MTV; i.e., the absolute and relative SUV values were reasonably close to commonly used values such as 2.5 and 40% of SUVmax. It is unclear, however, the etiology of the discordance superiorly, with the PET/CT showing high uptake at and above the endoscopically placed marker, potentially representing benign secondary esophagitis such as in the setting of luminal obstruction, the presence of malignant nodes, inflammation caused by the technical aspects of the fiducial placement itself, or potential submucosal disease. According to these findings, the incorporation of a fiducial marker inferiorly into the routine management of locally advanced esophageal cancer may offer an accurate target volume delineation when compared with 3D PET/CT. The factors confounding FDG uptake superiorly need further investigation to optimize GTV delineation. Author Disclosure: K. Latifi: None. J.A. Oliver: None. J. MontillaSoler: None. J. Klapman: None. G.C. Dhadham: None. C. Harris: None. K. Emanuel: None. J. Werner: None. J.M. Frakes: None. R.
Shridhar: None. T.J. Dilling: None. G.G. Zhang: None. E.G. Moros: None. S.E. Hoffe: None.
2450 Adjuvant Chemoradiation Therapy in Cholangiocarcinoma: A SingleInstitution Experience L.M. Rosati, V. Charu, A. Hacker-Prietz, PA-C, L. Zheng, D.P. Cosgrove, T.M. Pawlik, and J.M. Herman; Johns Hopkins University School of Medicine, Baltimore, MD Purpose/Objective(s): The role of adjuvant therapy in cholangiocarcinoma (CC) is largely unclear. This retrospective study was conducted to evaluate our institutional experience with adjuvant chemoradiation therapy (CRT) in intrahepatic (IH) and extrahepatic (EH) CC. Materials/Methods: The charts of 28 patients with IHCC or EHCC who received intensity-modulated radiation therapy with concurrent capecitabine chemotherapy from 2010 to 2014 at Johns Hopkins Hospital were reviewed. Survival estimates were calculated using Kaplan-Meier statistics. Results: Median time of follow-up was 16.1 months (months) from the end of CRT (range, 0.3-45.1). The median age at diagnosis was 62.4 years (range, 47-81) and 75% of patients were male. The majority (67.9%) of patients were diagnosed with EHCC whereas 32.1% had IHCC. Twentysix (93%) of the 28 patients were resected at our institution. Median tumor size was 1.9 cm (range, 0.8-10). The rate of margin-negative (R0) resection was 64%, and 30% of the 23 patients who underwent lymph node dissection achieved a node-negative resection. Twenty (71%) patients received upfront chemotherapy followed by CRT, 70% of which received 4 cycles of gemcitabine and capecitabine as administered in the Southwest Oncology Group (SWOG) S0809 phase II trial, whereas 29% of patients received upfront concurrent CRT. The median cumulative dose of RT was 52.5 Gray ([Gy] range, 30-54) in 2.1-Gy fractions (range, 1.82.2). Median overall survival (mOS) was 47.8 months (95% confidence interval [CI], 17.4-78.1). Rates of 1-year and 4-year survival were 92% and 45%, respectively. Patients with EHCC survived a median of 47.8 months in comparison with 33.5 months in IHCC (pZNS). Furthermore, a R0 resection (48.2 vs. 31.2 months, pZNS), lymph node dissection (47.8 vs. 31.2 months, pZNS) and upfront chemotherapy followed by CRT (50.8 vs. 31.2 months, pZNS), as opposed to upfront CRT, were associated with superior survival. Median progression-free survival was 30.9 months (95% CI, 10.7-51.2). In the 12 patients (43%) who were shown to have progressed on imaging, 7 (58%) progressed at a distant site first, 2 (17%) at a local site, and 3 (25%) experienced synchronous local and distant progression. Multivariate analyses revealed that the hazard of death among diabetic patients is 8.29 times that of non-diabetic patients (95% CI, 1.8-37.8) and that among patients undergoing upfront CRT is 4.77 times that of patients undergoing upfront chemotherapy prior to CRT (95% CI, 1.1-20.4). Conclusion: Despite the small numbers, this study suggests that adjuvant therapy may play a significant role in optimizing clinical outcomes in CC. Furthermore, our results support the sequence of therapy in EHCC prospectively evaluated in SWOG 0809. Prospective investigation of adjuvant therapy in IHCC is necessary. Author Disclosure: L.M. Rosati: None. V. Charu: None. A. HackerPrietz, PA-C: None. L. Zheng: None. D.P. Cosgrove: None. T.M. Pawlik: None. J.M. Herman: None.