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Modern Practice Patterns and Survival for Testicular Seminoma: Results from the National Cancer Data Base
Oral Scientific Sessions S133
Volume 90 Number 1S Supplement 2014 Purpose/Objective(s): Large changes in bladder shape and size during a course of radiation therapy (RT) make adaptive RT (ART) appealing in the treatment of this tumor site. We are conducting a two-center clinical phase II trial of daily plan selection based ART for bladder cancer with the primary aim of reducing gastro-intestinal morbidity due to sparing of the bowel and the rectum. We here report early dose/volume outcomes from the first twenty patients treated in this trial. Materials/Methods: All patients received 60 Gy in 30 fractions to the bladder; in thirteen of the patients the pelvic lymph nodes were simultaneously treated to 48 Gy. Daily patient set-up was by use of cone-beam CT (CBCT) guidance and treatment was delivered by volumetric modulated arc therapy (VMAT). The first five fractions were delivered using large, population-based margins; the bladder contours from the CBCTs acquired prior to the first four fractions were used to create a library of three plans, corresponding to a small, medium and large size bladder. All patients were from fraction no. 6 treated using daily online plan selection, where the smallest plan covering the bladder was selected prior to each treatment delivery. Volume ratios of PTV for ART vs. non-ART averaged over the treatment course were calculated. DVHs for bowel cavity and rectum were derived by summation of the selected plans and these were compared to standard non-adaptive RT plans using population-based margins. Results: The frequencies of which the small, medium, and large size plans were used over the (total of 600) fractions were similar; plans were used at a median of 9, 9.5 and 10 fractions, respectively. The median volume ratio of PTV-ART vs. non-ART across the treatment course was 0.70 (range: 0.46-0.89). The median rectal volume receiving 50 Gy or more was 5% (range: 0-41%), compared to 17% (range: 0-62%) if the patients had been treated with standard, non-adaptive RT. For the bowel cavity, the median volume receiving more than 45 Gy was 392 cm3 (range: 84-625 cm3), compared to 487 cm3 (range: 126-710 cm3) if not treated with adaptation. Conclusions: Daily adaptive plan selection in RT of bladder cancer results in a considerable normal tissue sparing, which is expected to reduce the risk of gastro-intestinal morbidity. Author Disclosure: L.P. Muren: None. E. Research Grant; Research grant from Varian Medical Systems to our dept., but not to the project described in the abstract. A. Vestergaard: None. H. Lindberg: None. K.L. Jakobsen: None. J.B.B. Petersen: None. U.V. Elstrøm: None. M. Høyer: None.
291 Modern Practice Patterns and Survival for Testicular Seminoma: Results from the National Cancer Data Base P.J. Gray,1 C. Lin,2 A. Jemal,2 and J.A. Efstathiou1; 1Massachusetts General Hospital, Boston, MA, 2American Cancer Society, Atlanta, GA Purpose/Objective(s): The management of testicular seminoma (TS) after orchiectomy is evolving, especially in patients with early-stage disease. We sought to investigate modern trends in the management of TS and to assess the effects of different adjuvant management strategies on survival. Materials/Methods: Data from the National Cancer Data Base on 41,745 patients with TS treated between 1998 and 2010 were analyzed. Logistic regression models were constructed to assess factors associated with adjuvant management paradigms. Cox proportional hazards models were used to analyze five-year survival in those diagnosed between 1998 and 2005. Results: Between 1998 and 2010, for patients with stage IA/B TS, rates of surveillance increased from 23.7% to 46.7% and receipt of adjuvant chemotherapy increased from 1.5% to 16.8%, while receipt of adjuvant radiation therapy decreased from 70.8% to 35.4%. For patients with stage IIA/B TS, receipt of adjuvant radiation therapy declined from 55.9% to 42.2% while receipt of chemotherapy rose from 20.4% to 40.6%. For those patients with stage IA/B TS, black or Hispanic race (OR Z 1.32 and 1.38 respectively vs. white, p both < 0.001) and lack of medical insurance (OR Z 1.29 vs. private insurance, p < 0.001) or insurance through Medicaid (OR Z 1.14 vs. private insurance, p Z
0.043) were associated with an increased odds of receiving surveillance while treatment at a high-volume center was associated with decreased odds (OR Z 0.63 vs. low-volume, p < 0.001). For stage IA/B and IIA/B patients who received adjuvant treatment, receipt of care at an NCIdesignated cancer center predicted for decreased receipt of radiation therapy vs. chemotherapy. Unadjusted five-year overall survival rates for patients with stage IA/B disease were 96.3% for surveillance, 98.0% for adjuvant radiation therapy and 94.4% for adjuvant chemotherapy. In a multivariate Cox regression model, receipt of adjuvant radiation therapy was associated with decreased hazard for death at five years (HR Z 0.65, p < 0.001) while receipt of adjuvant chemotherapy was associated with an increased hazard for death (HR Z 1.64, p Z 0.041) compared to receipt of surveillance after orchiectomy. Conclusions: Surveillance after orchiectomy for patients with stage I TS has increased in recent years. Receipt of adjuvant chemotherapy has also increased significantly in stage I and early stage II TS while receipt of radiation therapy has declined. In this large national dataset, patients with stage IA/B disease who receive radiation therapy appear to have improved five-year survival compared to those who receive surveillance or adjuvant chemotherapy. Additional study and longer follow-up (including assessment of late effects of treatment) are needed to validate these findings and confirm the appropriateness of these changing trends in management. Author Disclosure: P.J. Gray: None. C. Lin: None. A. Jemal: None. J.A. Efstathiou: None.
292 Long-Term Toxicity and Cosmetic Results of Partial Versus Whole Breast Irradiation: 10-Year Results of a Phase III APBI Trial C. Polgar, T. Major, Z. Sulyok, Z. Takacsi-Nagy, and J. Fodor; National Institute of Oncology, Budapest, Hungary Purpose/Objective(s): The 10-year survival results of a phase III study comparing breast-conserving treatment with partial (PBI) or whole breast irradiation (WBI) have been published recently. In this analysis long-term toxicity and cosmetic results are reported. Materials/Methods: Between 1998 and 2004, 258 selected, low-risk breast cancer patients were randomized after breast-conserving surgery to receive 50 Gy WBI (n Z 130) or PBI (n Z 128). The latter consisted of either 7 x 5.2 Gy high-dose-rate multicatheter brachytherapy (PBI-HDR; n Z 88) or 50 Gy electron beam irradiation (PBI-ELE; n Z 40). Late radiation side effects were scored by the RTOG/EORTC radiation morbidity scoring scheme. Cosmetic results were evaluated using the Harvard criteria. Follow-up mammograms were reviewed searching for visible signs of fat necrosis. Results: After a median follow-up of 10.2 years, skin side effects (any grade; G) occurred in 12.9%, 40.0%, and 20.5% in PBI-HDR, PBI-ELE, and WBI groups, respectively (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0009, pELE vs WBI Z NS). The respective rate of G3 telangiectasia was 0%, 7.5%, and 2.6% (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0311, pELE vs WBI Z NS). The rate of fibrosis (any G) was 49.4%, 22.5%, and 42.7% after PBI-HDR, PBI-ELE, and WBI, respectively (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0034, pELE vs WBI Z 0.0166). The respective rate of G3 fibrosis was only 2.4%, 0%, and 0.9%; p Z NS). Fat necrosis was detected on follow-up mammograms in 58.1%, 30.0%, and 52.1%, respectively (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0019, pELE vs WBI Z 0.0119). Only one patient (1.2%) in the PBI-HDR group developed fat necrosis requiring surgical intervention. The overall rate of G3 late toxicities was 2.4%, 7.5%, and 3.4% after PBI-HDR, PBI-ELE, and WBI, respectively (p Z NS). The rate of excellent-good cosmetic result was 81.2% in the PBI-HDR, 75.0% in the PBI-ELE, and 62.1% in the control group (pHDR vs WBI Z 0.0003, pHDR vs ELE Z NS, pELE vs WBI Z 0.0972). Conclusions: Significantly better cosmetic outcome can be achieved with carefully designed PBI-HDR multicatheter implants compared with the outcome after PBI-ELE or WBI. Both WBI and PBI (either with HDR or ELE) are well tolerated and severe late side effects are minimal. Slightly more parenchymal side effects occur after PBI-HDR. On the
Volume 90 Number 1S Supplement 2014 Purpose/Objective(s): Large changes in bladder shape and size during a course of radiation therapy (RT) make adaptive RT (ART) appealing in the treatment of this tumor site. We are conducting a two-center clinical phase II trial of daily plan selection based ART for bladder cancer with the primary aim of reducing gastro-intestinal morbidity due to sparing of the bowel and the rectum. We here report early dose/volume outcomes from the first twenty patients treated in this trial. Materials/Methods: All patients received 60 Gy in 30 fractions to the bladder; in thirteen of the patients the pelvic lymph nodes were simultaneously treated to 48 Gy. Daily patient set-up was by use of cone-beam CT (CBCT) guidance and treatment was delivered by volumetric modulated arc therapy (VMAT). The first five fractions were delivered using large, population-based margins; the bladder contours from the CBCTs acquired prior to the first four fractions were used to create a library of three plans, corresponding to a small, medium and large size bladder. All patients were from fraction no. 6 treated using daily online plan selection, where the smallest plan covering the bladder was selected prior to each treatment delivery. Volume ratios of PTV for ART vs. non-ART averaged over the treatment course were calculated. DVHs for bowel cavity and rectum were derived by summation of the selected plans and these were compared to standard non-adaptive RT plans using population-based margins. Results: The frequencies of which the small, medium, and large size plans were used over the (total of 600) fractions were similar; plans were used at a median of 9, 9.5 and 10 fractions, respectively. The median volume ratio of PTV-ART vs. non-ART across the treatment course was 0.70 (range: 0.46-0.89). The median rectal volume receiving 50 Gy or more was 5% (range: 0-41%), compared to 17% (range: 0-62%) if the patients had been treated with standard, non-adaptive RT. For the bowel cavity, the median volume receiving more than 45 Gy was 392 cm3 (range: 84-625 cm3), compared to 487 cm3 (range: 126-710 cm3) if not treated with adaptation. Conclusions: Daily adaptive plan selection in RT of bladder cancer results in a considerable normal tissue sparing, which is expected to reduce the risk of gastro-intestinal morbidity. Author Disclosure: L.P. Muren: None. E. Research Grant; Research grant from Varian Medical Systems to our dept., but not to the project described in the abstract. A. Vestergaard: None. H. Lindberg: None. K.L. Jakobsen: None. J.B.B. Petersen: None. U.V. Elstrøm: None. M. Høyer: None.
291 Modern Practice Patterns and Survival for Testicular Seminoma: Results from the National Cancer Data Base P.J. Gray,1 C. Lin,2 A. Jemal,2 and J.A. Efstathiou1; 1Massachusetts General Hospital, Boston, MA, 2American Cancer Society, Atlanta, GA Purpose/Objective(s): The management of testicular seminoma (TS) after orchiectomy is evolving, especially in patients with early-stage disease. We sought to investigate modern trends in the management of TS and to assess the effects of different adjuvant management strategies on survival. Materials/Methods: Data from the National Cancer Data Base on 41,745 patients with TS treated between 1998 and 2010 were analyzed. Logistic regression models were constructed to assess factors associated with adjuvant management paradigms. Cox proportional hazards models were used to analyze five-year survival in those diagnosed between 1998 and 2005. Results: Between 1998 and 2010, for patients with stage IA/B TS, rates of surveillance increased from 23.7% to 46.7% and receipt of adjuvant chemotherapy increased from 1.5% to 16.8%, while receipt of adjuvant radiation therapy decreased from 70.8% to 35.4%. For patients with stage IIA/B TS, receipt of adjuvant radiation therapy declined from 55.9% to 42.2% while receipt of chemotherapy rose from 20.4% to 40.6%. For those patients with stage IA/B TS, black or Hispanic race (OR Z 1.32 and 1.38 respectively vs. white, p both < 0.001) and lack of medical insurance (OR Z 1.29 vs. private insurance, p < 0.001) or insurance through Medicaid (OR Z 1.14 vs. private insurance, p Z
0.043) were associated with an increased odds of receiving surveillance while treatment at a high-volume center was associated with decreased odds (OR Z 0.63 vs. low-volume, p < 0.001). For stage IA/B and IIA/B patients who received adjuvant treatment, receipt of care at an NCIdesignated cancer center predicted for decreased receipt of radiation therapy vs. chemotherapy. Unadjusted five-year overall survival rates for patients with stage IA/B disease were 96.3% for surveillance, 98.0% for adjuvant radiation therapy and 94.4% for adjuvant chemotherapy. In a multivariate Cox regression model, receipt of adjuvant radiation therapy was associated with decreased hazard for death at five years (HR Z 0.65, p < 0.001) while receipt of adjuvant chemotherapy was associated with an increased hazard for death (HR Z 1.64, p Z 0.041) compared to receipt of surveillance after orchiectomy. Conclusions: Surveillance after orchiectomy for patients with stage I TS has increased in recent years. Receipt of adjuvant chemotherapy has also increased significantly in stage I and early stage II TS while receipt of radiation therapy has declined. In this large national dataset, patients with stage IA/B disease who receive radiation therapy appear to have improved five-year survival compared to those who receive surveillance or adjuvant chemotherapy. Additional study and longer follow-up (including assessment of late effects of treatment) are needed to validate these findings and confirm the appropriateness of these changing trends in management. Author Disclosure: P.J. Gray: None. C. Lin: None. A. Jemal: None. J.A. Efstathiou: None.
292 Long-Term Toxicity and Cosmetic Results of Partial Versus Whole Breast Irradiation: 10-Year Results of a Phase III APBI Trial C. Polgar, T. Major, Z. Sulyok, Z. Takacsi-Nagy, and J. Fodor; National Institute of Oncology, Budapest, Hungary Purpose/Objective(s): The 10-year survival results of a phase III study comparing breast-conserving treatment with partial (PBI) or whole breast irradiation (WBI) have been published recently. In this analysis long-term toxicity and cosmetic results are reported. Materials/Methods: Between 1998 and 2004, 258 selected, low-risk breast cancer patients were randomized after breast-conserving surgery to receive 50 Gy WBI (n Z 130) or PBI (n Z 128). The latter consisted of either 7 x 5.2 Gy high-dose-rate multicatheter brachytherapy (PBI-HDR; n Z 88) or 50 Gy electron beam irradiation (PBI-ELE; n Z 40). Late radiation side effects were scored by the RTOG/EORTC radiation morbidity scoring scheme. Cosmetic results were evaluated using the Harvard criteria. Follow-up mammograms were reviewed searching for visible signs of fat necrosis. Results: After a median follow-up of 10.2 years, skin side effects (any grade; G) occurred in 12.9%, 40.0%, and 20.5% in PBI-HDR, PBI-ELE, and WBI groups, respectively (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0009, pELE vs WBI Z NS). The respective rate of G3 telangiectasia was 0%, 7.5%, and 2.6% (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0311, pELE vs WBI Z NS). The rate of fibrosis (any G) was 49.4%, 22.5%, and 42.7% after PBI-HDR, PBI-ELE, and WBI, respectively (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0034, pELE vs WBI Z 0.0166). The respective rate of G3 fibrosis was only 2.4%, 0%, and 0.9%; p Z NS). Fat necrosis was detected on follow-up mammograms in 58.1%, 30.0%, and 52.1%, respectively (pHDR vs WBI Z NS, pHDR vs ELE Z 0.0019, pELE vs WBI Z 0.0119). Only one patient (1.2%) in the PBI-HDR group developed fat necrosis requiring surgical intervention. The overall rate of G3 late toxicities was 2.4%, 7.5%, and 3.4% after PBI-HDR, PBI-ELE, and WBI, respectively (p Z NS). The rate of excellent-good cosmetic result was 81.2% in the PBI-HDR, 75.0% in the PBI-ELE, and 62.1% in the control group (pHDR vs WBI Z 0.0003, pHDR vs ELE Z NS, pELE vs WBI Z 0.0972). Conclusions: Significantly better cosmetic outcome can be achieved with carefully designed PBI-HDR multicatheter implants compared with the outcome after PBI-ELE or WBI. Both WBI and PBI (either with HDR or ELE) are well tolerated and severe late side effects are minimal. Slightly more parenchymal side effects occur after PBI-HDR. On the