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Managing Local Recurrence After Primary Resection of Non-Small Cell Lung Cancer: The Role for Salvage Stereotactic Body Radiation Therapy
E472
International Journal of Radiation Oncology Biology Physics
patients (3 patients had continued unresectability, 1 had metastatic disease at restaging, 1 declined surgery and 1 unknown), of whom 77% also received subsequent consolidation chemotherapy. With a median follow up of 31 months (maximum 175 months), occurrence of MNC at surgical sampling resulted in improved OS and FFR (table). Of the 69 patients who underwent resection, pCR at the primary tumor was seen in 36/69 (52%) patients. Occurrence of pCR at the primary tumor in these resected patients did not result in differences in OS or FFR (table). No consistent trend is seen when stratifying with the use of consolidation chemotherapy. Conclusion: As shown in prior studies, MNC after CRT is predictive of improved OS and FFR for patients undergoing trimodality therapy. However, the additional advantage of a pCR in the primary for patients undergoing a resection has limited impact on OS and FFR. Therefore, future therapies should focus on improving MNC to encourage more frequent use of surgery. Author Disclosure: M. Vyfhuis: None. N. Bhooshan: None. J. Feliciano: None. W. Burrows: None. E.M. Nichols: None. S.M. Bentzen: Executive Director; ICRU. M.J. Edelman: None. M. Suntharalingam: None. S. Carr: None. J. Friedberg: None. S.J. Feigenberg: None. P. Mohindra: None.
after salvage SBRT was 12 months. Eleven patients remain alive and free of disease after treatment. Two patients developed grade III toxicity (atelectasis and soft tissue necrosis) following treatment. Distant failure was seen in 35% of cases, with a median time to distant failure of 13 months. 8 of these patients underwent systemic therapy following distant failure. Conclusion: For patients deemed medically inoperable for surgical salvage, lung SBRT for salvage appears well-tolerated and provides effective local control. Although cure may be achieved in some cases, distant failure remains the primary pattern of failure. Author Disclosure: A. Juloori: None. A.D. Vassil: None. N.M. Woody: None. K.L. Stephans: None. G.M. Videtic: None.
3161 Managing Local Recurrence After Primary Resection of Non-Small Cell Lung Cancer: The Role for Salvage Stereotactic Body Radiation Therapy A. Juloori,1 A.D. Vassil,2 N.M. Woody,1 K.L. Stephans,1 and G.M. Videtic1; 1Cleveland Clinic, Cleveland, OH, 2Strongsville FHC, Strongville, OH Purpose/Objective(s): Surgery is the standard of care treatment for patients with medically operable, early stage non-small cell lung cancer (NSCLC). While stereotactic body radiation therapy (SBRT) is well established as primary therapy for those patients who are up-front medically inoperable, it has also been utilized as definitive salvage in patients who have a local recurrence following primary resection. Given the limited reports on outcomes after salvage SBRT for surgical failures, we surveyed our large institutional database to further characterize this population. Materials/Methods: From an IRB-approved prospective lung SBRT registry, 40 patients were identified between 2004 and 2015 whose treatment intent was salvage for local recurrence after previous surgery. Following SBRT, failure was defined radiographically by CT and/or PET and was confirmed histologically unless contraindicated. Toxicities were graded according to Common Terminology Criteria for Adverse Events version 4. Local control (LC) and overall survival (OS) were assessed using KaplanMeier estimates. Results: Of the 40 patients in this analysis, 18 had initial wedge resection, 18 had lobectomy, 2 had segmentectomy, and 2 patients had bilobectomy. 30 patients had stage I disease, 4 had stage II, 2 had IIIA, and 4 were characterized as early stage disease, otherwise not specified. Median time between surgery and diagnosis of local failure was 25 months (range 3 e 101 months). All patients were N0M0 at recurrence with rT stages of T1, T2 T3, and T4 in 25, 10, 4, and 1 patient(s) respectively. 39 patients had PET and 8 patients had mediastinal staging with either EBUS or mediastinoscopy. Given that in this series all patients were deemed inoperable at recurrence, 21 patients were deemed inoperable due to poor pulmonary function. However, 2 patients refused surgery. Median time from diagnosis of recurrence to initiation of salvage SBRT was 48 days. Median age and KPS at treatment were 74.9 years and 80 respectively. There was equal distribution between central and peripheral lesions. The most common regimen was 50 Gy in 5 fractions (67.5%). With a median follow-up of 18.9 months, only 5 patients developed a local recurrence. Eighteen-month OS and LC were 77.6% and 87% respectively. Median time to local failure
3162 Implanted Electromagnetic Transponders for Monitoring Deep Inspiration Breath Hold: Interim Results of a Prospective Feasibility Study A. Rimner, E.D. Yorke, R. Lee, M. Chawla, E. Gelb, D. Gelblum, D. von Reibnitz, A.J. Wu, and M. Lovelock; Memorial Sloan Kettering Cancer Center, New York, NY Purpose/Objective(s): The hypothesis is that implanted electromagnetic transponders can be used in deep inspiration breath hold RT of lung tumors to improve the accuracy of dose delivery. Materials/Methods: Patients with primary or metastatic lung tumors were eligible for this prospective IRB-approved protocol under an IDE. Patients had to be able to at minimum hold their breath 5 times for >20 seconds. 3 transponders were implanted by navigational bronchoscopy in 2.5mm airways near the tumor. After > 3 days, patients were simulated with a coached DIBH, a free-breathing (FB) and a 4DCT scan for a backup plan. The transponder coordinates, relative to isocenter, were used to gate treatment such that the target had to be within 5 mm of its planned position for dose delivery to occur. For initial setup, a therapist coached the patient to DIBH and adjusted the couch to bring the transponder centroid within 2 mm of the planned position. Patients treated with stereotactic body radiation therapy (SBRT) (nZ14) underwent a cone beam-CT (CBCT) in breath-hold position at each treatment. The final setup was determined by a tumor match with the planning scan. An adjustment in the centroid parameters was made if necessary to match the imaging findings. Conventionally fractionated patients (nZ4) received a weekly CBCT for tumor match and were on other days set up based on the transponder centroid. All patients received daily orthogonal imaging and were treated in multiple DIBHs. Results: 18 patients were enrolled thus far and 5 have >12 months follow up (median 6.6 months). Only 1/54 transponder was found more peripheral than intended at the time of implantation. No transponder migration or loss was observed. All patients were able to perform reliable DIBH maneuvers throughout treatment. One patient had to interrupt treatment due to a shoulder problem. Another patient had to be instructed to perform chest rather than abdominal breathing to avoid collision with the antenna. CBCTs could be acquired in 1-3 breath-holds. DIBH significantly increased lung volume and decreased PTV volume relative to FB. Lung metrics in DIBH plans were far superior to the FB plans; in 7 patients FB plans could not simultaneously meet the DIBH prescription and satisfy dosimetric constraints. No patients experienced implantation-related toxicity and no unexpected treatment-related toxicities were observed. One patient developed grade 3 pneumonia in the involved right lower lobe 4 months after completion of treatment which was considered to be possibly related to the transponder location. Conclusion: Using implanted transponders to gate DIBH treatments of selected lung tumor patients is clinically feasible and well tolerated. Transponder-guided DIBH resulted in significant benefits in target positioning and monitoring for accurate DIBH treatment delivery and decreased RT dose to organs at risk.
International Journal of Radiation Oncology Biology Physics
patients (3 patients had continued unresectability, 1 had metastatic disease at restaging, 1 declined surgery and 1 unknown), of whom 77% also received subsequent consolidation chemotherapy. With a median follow up of 31 months (maximum 175 months), occurrence of MNC at surgical sampling resulted in improved OS and FFR (table). Of the 69 patients who underwent resection, pCR at the primary tumor was seen in 36/69 (52%) patients. Occurrence of pCR at the primary tumor in these resected patients did not result in differences in OS or FFR (table). No consistent trend is seen when stratifying with the use of consolidation chemotherapy. Conclusion: As shown in prior studies, MNC after CRT is predictive of improved OS and FFR for patients undergoing trimodality therapy. However, the additional advantage of a pCR in the primary for patients undergoing a resection has limited impact on OS and FFR. Therefore, future therapies should focus on improving MNC to encourage more frequent use of surgery. Author Disclosure: M. Vyfhuis: None. N. Bhooshan: None. J. Feliciano: None. W. Burrows: None. E.M. Nichols: None. S.M. Bentzen: Executive Director; ICRU. M.J. Edelman: None. M. Suntharalingam: None. S. Carr: None. J. Friedberg: None. S.J. Feigenberg: None. P. Mohindra: None.
after salvage SBRT was 12 months. Eleven patients remain alive and free of disease after treatment. Two patients developed grade III toxicity (atelectasis and soft tissue necrosis) following treatment. Distant failure was seen in 35% of cases, with a median time to distant failure of 13 months. 8 of these patients underwent systemic therapy following distant failure. Conclusion: For patients deemed medically inoperable for surgical salvage, lung SBRT for salvage appears well-tolerated and provides effective local control. Although cure may be achieved in some cases, distant failure remains the primary pattern of failure. Author Disclosure: A. Juloori: None. A.D. Vassil: None. N.M. Woody: None. K.L. Stephans: None. G.M. Videtic: None.
3161 Managing Local Recurrence After Primary Resection of Non-Small Cell Lung Cancer: The Role for Salvage Stereotactic Body Radiation Therapy A. Juloori,1 A.D. Vassil,2 N.M. Woody,1 K.L. Stephans,1 and G.M. Videtic1; 1Cleveland Clinic, Cleveland, OH, 2Strongsville FHC, Strongville, OH Purpose/Objective(s): Surgery is the standard of care treatment for patients with medically operable, early stage non-small cell lung cancer (NSCLC). While stereotactic body radiation therapy (SBRT) is well established as primary therapy for those patients who are up-front medically inoperable, it has also been utilized as definitive salvage in patients who have a local recurrence following primary resection. Given the limited reports on outcomes after salvage SBRT for surgical failures, we surveyed our large institutional database to further characterize this population. Materials/Methods: From an IRB-approved prospective lung SBRT registry, 40 patients were identified between 2004 and 2015 whose treatment intent was salvage for local recurrence after previous surgery. Following SBRT, failure was defined radiographically by CT and/or PET and was confirmed histologically unless contraindicated. Toxicities were graded according to Common Terminology Criteria for Adverse Events version 4. Local control (LC) and overall survival (OS) were assessed using KaplanMeier estimates. Results: Of the 40 patients in this analysis, 18 had initial wedge resection, 18 had lobectomy, 2 had segmentectomy, and 2 patients had bilobectomy. 30 patients had stage I disease, 4 had stage II, 2 had IIIA, and 4 were characterized as early stage disease, otherwise not specified. Median time between surgery and diagnosis of local failure was 25 months (range 3 e 101 months). All patients were N0M0 at recurrence with rT stages of T1, T2 T3, and T4 in 25, 10, 4, and 1 patient(s) respectively. 39 patients had PET and 8 patients had mediastinal staging with either EBUS or mediastinoscopy. Given that in this series all patients were deemed inoperable at recurrence, 21 patients were deemed inoperable due to poor pulmonary function. However, 2 patients refused surgery. Median time from diagnosis of recurrence to initiation of salvage SBRT was 48 days. Median age and KPS at treatment were 74.9 years and 80 respectively. There was equal distribution between central and peripheral lesions. The most common regimen was 50 Gy in 5 fractions (67.5%). With a median follow-up of 18.9 months, only 5 patients developed a local recurrence. Eighteen-month OS and LC were 77.6% and 87% respectively. Median time to local failure
3162 Implanted Electromagnetic Transponders for Monitoring Deep Inspiration Breath Hold: Interim Results of a Prospective Feasibility Study A. Rimner, E.D. Yorke, R. Lee, M. Chawla, E. Gelb, D. Gelblum, D. von Reibnitz, A.J. Wu, and M. Lovelock; Memorial Sloan Kettering Cancer Center, New York, NY Purpose/Objective(s): The hypothesis is that implanted electromagnetic transponders can be used in deep inspiration breath hold RT of lung tumors to improve the accuracy of dose delivery. Materials/Methods: Patients with primary or metastatic lung tumors were eligible for this prospective IRB-approved protocol under an IDE. Patients had to be able to at minimum hold their breath 5 times for >20 seconds. 3 transponders were implanted by navigational bronchoscopy in 2.5mm airways near the tumor. After > 3 days, patients were simulated with a coached DIBH, a free-breathing (FB) and a 4DCT scan for a backup plan. The transponder coordinates, relative to isocenter, were used to gate treatment such that the target had to be within 5 mm of its planned position for dose delivery to occur. For initial setup, a therapist coached the patient to DIBH and adjusted the couch to bring the transponder centroid within 2 mm of the planned position. Patients treated with stereotactic body radiation therapy (SBRT) (nZ14) underwent a cone beam-CT (CBCT) in breath-hold position at each treatment. The final setup was determined by a tumor match with the planning scan. An adjustment in the centroid parameters was made if necessary to match the imaging findings. Conventionally fractionated patients (nZ4) received a weekly CBCT for tumor match and were on other days set up based on the transponder centroid. All patients received daily orthogonal imaging and were treated in multiple DIBHs. Results: 18 patients were enrolled thus far and 5 have >12 months follow up (median 6.6 months). Only 1/54 transponder was found more peripheral than intended at the time of implantation. No transponder migration or loss was observed. All patients were able to perform reliable DIBH maneuvers throughout treatment. One patient had to interrupt treatment due to a shoulder problem. Another patient had to be instructed to perform chest rather than abdominal breathing to avoid collision with the antenna. CBCTs could be acquired in 1-3 breath-holds. DIBH significantly increased lung volume and decreased PTV volume relative to FB. Lung metrics in DIBH plans were far superior to the FB plans; in 7 patients FB plans could not simultaneously meet the DIBH prescription and satisfy dosimetric constraints. No patients experienced implantation-related toxicity and no unexpected treatment-related toxicities were observed. One patient developed grade 3 pneumonia in the involved right lower lobe 4 months after completion of treatment which was considered to be possibly related to the transponder location. Conclusion: Using implanted transponders to gate DIBH treatments of selected lung tumor patients is clinically feasible and well tolerated. Transponder-guided DIBH resulted in significant benefits in target positioning and monitoring for accurate DIBH treatment delivery and decreased RT dose to organs at risk.