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Locally Advanced and Unresectable Cutaneous Squamous Cell Carcinoma: Outcomes of Concurrent Cetuximab and Radiation Therapy
Poster Viewing Abstracts S761
Volume 90 Number 1S Supplement 2014
3397 Locally Advanced and Unresectable Cutaneous Squamous Cell Carcinoma: Outcomes of Concurrent Cetuximab and Radiation Therapy C.A. Barker, R.M. Samstein, and N.Y. Lee; Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): Advanced age and immune dysfunction are risk factors for cutaneous squamous cell carcinoma (cSCC) and often render patients with locally advanced disease medically inoperable or surgically unresectable. In these patients, radiation therapy can be curative. Concurrent systemic and radiation therapy might improve the outcome of treatment, but in elderly patients with comorbidities and immune dysfunction cytotoxic chemotherapy is not well-tolerated. However, cetuximab has demonstrated activity in cSCC, and is known to interact with radiation therapy to improve outcome. For this reason, we have used cetuximab concurrent with radiation therapy (CRT) for patients with locally advanced and unresectable cSCC that are not candidates for chemotherapy during radiation therapy. Given the limited published data with this approach, we hypothesized that CRT would be well-tolerated and associated with favorable response rates and disease control. Materials/Methods: Medical records of patients treated with CRT for cSCC were reviewed with permission of the institutional review board. Demographic, comorbidity (according to the ACE-27) and treatment details were recorded. Adverse events were classified according to CTCAE, version 4.0. Treatment response was recorded, and progression-free, cSCC-specific and overall survival was calculated using Kaplan-Meier methods. Results: Twelve patients were selected for CRT. Median age was 77, and 75% had moderate or severe comorbidities. Identifiable immune dysfunction was present in 42%. Two patients had distant metastasis, and all patients had locally advanced (T4 tumors) or regional lymph node metastasis at start of CRT. One patient was given adjuvant treatment, while all others had recurrent gross disease at start of CRT. Median dose of radiation and cetuximab was 60 Gy and 1525 mg/m^2, respectively. Grade 3-4 adverse events were noted in 83% of patients; 67% required hospital admission for adverse events. Complete and partial response was noted in 36% and 27%, for a response rate of 64% (95% confidence interval 35-92%). Stable and progressive disease was noted in 3 and 1 patients, respectively, for a disease control rate of 91% (95% confidence interval 74-100%). With a median follow-up of 33.6 months for surviving patients, median progression-free, cSCCspecific and overall survival was 5.5, 33, and 15 months, respectively. Survival was inferior among patients with distant metastasis, immune dysfunction, and moderate or severe comorbidities, compared to those without. Conclusions: Patients selected for CRT at our center were elderly, with comorbidities and immune dysfunction, but despite this, treatment responses were observed. These results also suggest that the patients we have selected for this treatment approach have a poor prognosis and limited capacity for therapy. Additional studies are needed to further improve outcomes. Author Disclosure: C.A. Barker: A. Employee; Memorial Sloan Kettering Cancer Center. E. Research Grant; ASTRO. G. Consultant; RP Pharmaceuticals, Nucletron. I. Travel Expenses; MASCC, Nucletron. S. Leadership; ASTRO. R.M. Samstein: None. N.Y. Lee: A. Employee; Memorial Sloan Kettering Cancer Center.
3398 IMRT for Angiosarcoma of the Scalp Using Tomotherapy: Planning Study and the Initial Results K. Karasawa, S. Kageyama, S. KItou, Y. Shibata, K. Ito, T. Shimizuguchi, H. Murata, H. Tanaka, K. Nihei, and K. Yoshino; Tokyo Metro Komagome Hospital, Tokyo, Japan
Purpose/Objective(s): Angiosarcoma of the scalp is relatively rare disease and affects mainly elderly patients. It is very difficult to control primary tumor as well as distant metastases. The mainstay of the treatment is surgical resection combined with chemoradiation therapy (CRT). However, it often progresses rapidly and becomes unresectable at the initial presentation. Thus we often treat this disease with definitive CRT. Conventional photon beam treatment would have irradiated underlying normal brain tissue, thus not suitable for treatment. Therefore, we used electron beams of certain energy. However, it is quite difficult to irradiate the targets homogenously lying on the surface of spheres by any shape of cone of the electron beam for fear of overlapping of the fields. Tomotherapy, on the other hand, has known to be capable of hollowing out such kind of normal tissue and thus we used it for the treatment of this disease since 2013. In this study, dose distributions by tomotherapy and by Segmental MLCIMRT(SMLC-IMRT) in 3 cases were compared and their clinical responses treated by Tomotherapy were evaluated. Materials/Methods: Initial clinical target volume (CTV1) was set to be gross tumor volume (GTV) and suspected involved areas such as purpura and edema plus 2 to 3 cm margin. Cone down CTV (CTV2) was set to be GTV and suspected involved areas plus appropriate margin decided by Dermatologist. PTV margin was set to be 0.5 cm for both targets (PTV1 and PTV2). We irradiate 60 Gy / 30 fractions to the PTV1 with the 10 Gy / 5 fractions of boost to the PTV2. Concurrent chemotherapy was given with weekly paclitaxel (PTX) at the dose of 60 mg/m2. Following the completion of concurrent CRT, weekly PTX at the dose of 60 mg/m2 was given until progression. Results: So far, we treated 5 patients. Among them, we compared the dose distributions between tomotherapy and SMLC-IMRT in 3 cases. Average of the maximum, mean, and minimum PTV2 doses were, 78.0 +/- 1.6 Gy, 69.6 +/- 0.8 Gy, and 46.0 +/- 4.4 Gy, respectively for tomotherapy, and 83.5 +/- 1.6 Gy, 69.5 +/- 1.0 Gy, and 23.2 +/- 9.1 Gy, respectively, for SMLC-IMRT. As for minimum PTV2 dose was significantly higher for tomotherapy (p Z 0.0175). Regarding normal tissue dose, the average of maximum and mean cerebral doses were 68.3 +/- 1.9 Gy, and 20.9 +/- 6.8 Gy, respectively for tomotherapy and 73.6 +/- 5.3 Gy, and 27.1 Gy +/11.4 Gy, respectively for SMLC-IMRT. As for clinical response, there were 1 CR and 4 PRs. No local relapse has been observed. There was 1 grade 3 acute neurotoxicity complicated by bacterial septic shock and 2 grade 3 skin toxicities. Conclusions: Tomotherapy provided more homogenous PTV dose compared with SMLC-IMRT. Our initial results were promising with acceptable toxicities. Author Disclosure: K. Karasawa: None. S. Kageyama: None. S. KItou: None. Y. Shibata: None. K. Ito: None. T. Shimizuguchi: None. H. Murata: None. H. Tanaka: None. K. Nihei: None. K. Yoshino: None.
3399 Tangential Modulated Arc Therapy: A Novel Technique for the Treatment of Superficial Disease M.J. Hadsell, L. Million, K. Horst, and K. Bush; Stanford University, Stanford, CA Purpose/Objective(s): In recent decades, great leaps forward in the treatment of deep-seated cancers have been made using arcs and static fields of intensity modulated megavoltage photon radiation. However, the treatment of more superficial lesions has made comparatively fewer advances, with breast treatments still relying on opposed tangent photon fields coupled with electron boosts and skin surface sarcomas being treated with superficial radionuclides or unmodulated electron fields and arcs. We propose a new type of treatment that employs a modulated and sliding tangential photon field to provide superior coverage of such superficial target volumes while drastically reducing dose to the underlying sensitive structures often present in these cases.
Volume 90 Number 1S Supplement 2014
3397 Locally Advanced and Unresectable Cutaneous Squamous Cell Carcinoma: Outcomes of Concurrent Cetuximab and Radiation Therapy C.A. Barker, R.M. Samstein, and N.Y. Lee; Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): Advanced age and immune dysfunction are risk factors for cutaneous squamous cell carcinoma (cSCC) and often render patients with locally advanced disease medically inoperable or surgically unresectable. In these patients, radiation therapy can be curative. Concurrent systemic and radiation therapy might improve the outcome of treatment, but in elderly patients with comorbidities and immune dysfunction cytotoxic chemotherapy is not well-tolerated. However, cetuximab has demonstrated activity in cSCC, and is known to interact with radiation therapy to improve outcome. For this reason, we have used cetuximab concurrent with radiation therapy (CRT) for patients with locally advanced and unresectable cSCC that are not candidates for chemotherapy during radiation therapy. Given the limited published data with this approach, we hypothesized that CRT would be well-tolerated and associated with favorable response rates and disease control. Materials/Methods: Medical records of patients treated with CRT for cSCC were reviewed with permission of the institutional review board. Demographic, comorbidity (according to the ACE-27) and treatment details were recorded. Adverse events were classified according to CTCAE, version 4.0. Treatment response was recorded, and progression-free, cSCC-specific and overall survival was calculated using Kaplan-Meier methods. Results: Twelve patients were selected for CRT. Median age was 77, and 75% had moderate or severe comorbidities. Identifiable immune dysfunction was present in 42%. Two patients had distant metastasis, and all patients had locally advanced (T4 tumors) or regional lymph node metastasis at start of CRT. One patient was given adjuvant treatment, while all others had recurrent gross disease at start of CRT. Median dose of radiation and cetuximab was 60 Gy and 1525 mg/m^2, respectively. Grade 3-4 adverse events were noted in 83% of patients; 67% required hospital admission for adverse events. Complete and partial response was noted in 36% and 27%, for a response rate of 64% (95% confidence interval 35-92%). Stable and progressive disease was noted in 3 and 1 patients, respectively, for a disease control rate of 91% (95% confidence interval 74-100%). With a median follow-up of 33.6 months for surviving patients, median progression-free, cSCCspecific and overall survival was 5.5, 33, and 15 months, respectively. Survival was inferior among patients with distant metastasis, immune dysfunction, and moderate or severe comorbidities, compared to those without. Conclusions: Patients selected for CRT at our center were elderly, with comorbidities and immune dysfunction, but despite this, treatment responses were observed. These results also suggest that the patients we have selected for this treatment approach have a poor prognosis and limited capacity for therapy. Additional studies are needed to further improve outcomes. Author Disclosure: C.A. Barker: A. Employee; Memorial Sloan Kettering Cancer Center. E. Research Grant; ASTRO. G. Consultant; RP Pharmaceuticals, Nucletron. I. Travel Expenses; MASCC, Nucletron. S. Leadership; ASTRO. R.M. Samstein: None. N.Y. Lee: A. Employee; Memorial Sloan Kettering Cancer Center.
3398 IMRT for Angiosarcoma of the Scalp Using Tomotherapy: Planning Study and the Initial Results K. Karasawa, S. Kageyama, S. KItou, Y. Shibata, K. Ito, T. Shimizuguchi, H. Murata, H. Tanaka, K. Nihei, and K. Yoshino; Tokyo Metro Komagome Hospital, Tokyo, Japan
Purpose/Objective(s): Angiosarcoma of the scalp is relatively rare disease and affects mainly elderly patients. It is very difficult to control primary tumor as well as distant metastases. The mainstay of the treatment is surgical resection combined with chemoradiation therapy (CRT). However, it often progresses rapidly and becomes unresectable at the initial presentation. Thus we often treat this disease with definitive CRT. Conventional photon beam treatment would have irradiated underlying normal brain tissue, thus not suitable for treatment. Therefore, we used electron beams of certain energy. However, it is quite difficult to irradiate the targets homogenously lying on the surface of spheres by any shape of cone of the electron beam for fear of overlapping of the fields. Tomotherapy, on the other hand, has known to be capable of hollowing out such kind of normal tissue and thus we used it for the treatment of this disease since 2013. In this study, dose distributions by tomotherapy and by Segmental MLCIMRT(SMLC-IMRT) in 3 cases were compared and their clinical responses treated by Tomotherapy were evaluated. Materials/Methods: Initial clinical target volume (CTV1) was set to be gross tumor volume (GTV) and suspected involved areas such as purpura and edema plus 2 to 3 cm margin. Cone down CTV (CTV2) was set to be GTV and suspected involved areas plus appropriate margin decided by Dermatologist. PTV margin was set to be 0.5 cm for both targets (PTV1 and PTV2). We irradiate 60 Gy / 30 fractions to the PTV1 with the 10 Gy / 5 fractions of boost to the PTV2. Concurrent chemotherapy was given with weekly paclitaxel (PTX) at the dose of 60 mg/m2. Following the completion of concurrent CRT, weekly PTX at the dose of 60 mg/m2 was given until progression. Results: So far, we treated 5 patients. Among them, we compared the dose distributions between tomotherapy and SMLC-IMRT in 3 cases. Average of the maximum, mean, and minimum PTV2 doses were, 78.0 +/- 1.6 Gy, 69.6 +/- 0.8 Gy, and 46.0 +/- 4.4 Gy, respectively for tomotherapy, and 83.5 +/- 1.6 Gy, 69.5 +/- 1.0 Gy, and 23.2 +/- 9.1 Gy, respectively, for SMLC-IMRT. As for minimum PTV2 dose was significantly higher for tomotherapy (p Z 0.0175). Regarding normal tissue dose, the average of maximum and mean cerebral doses were 68.3 +/- 1.9 Gy, and 20.9 +/- 6.8 Gy, respectively for tomotherapy and 73.6 +/- 5.3 Gy, and 27.1 Gy +/11.4 Gy, respectively for SMLC-IMRT. As for clinical response, there were 1 CR and 4 PRs. No local relapse has been observed. There was 1 grade 3 acute neurotoxicity complicated by bacterial septic shock and 2 grade 3 skin toxicities. Conclusions: Tomotherapy provided more homogenous PTV dose compared with SMLC-IMRT. Our initial results were promising with acceptable toxicities. Author Disclosure: K. Karasawa: None. S. Kageyama: None. S. KItou: None. Y. Shibata: None. K. Ito: None. T. Shimizuguchi: None. H. Murata: None. H. Tanaka: None. K. Nihei: None. K. Yoshino: None.
3399 Tangential Modulated Arc Therapy: A Novel Technique for the Treatment of Superficial Disease M.J. Hadsell, L. Million, K. Horst, and K. Bush; Stanford University, Stanford, CA Purpose/Objective(s): In recent decades, great leaps forward in the treatment of deep-seated cancers have been made using arcs and static fields of intensity modulated megavoltage photon radiation. However, the treatment of more superficial lesions has made comparatively fewer advances, with breast treatments still relying on opposed tangent photon fields coupled with electron boosts and skin surface sarcomas being treated with superficial radionuclides or unmodulated electron fields and arcs. We propose a new type of treatment that employs a modulated and sliding tangential photon field to provide superior coverage of such superficial target volumes while drastically reducing dose to the underlying sensitive structures often present in these cases.