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Multi-Institutional Soft Tissue Sarcoma Real-Time Peer Review Radiation Therapy Quality Assurance Rounds
Volume 96 Number 2S Supplement 2016 combination (ACRT), neoadjuvant chemoradiotherapy combination (NCRT), and mixed (M) CRT (NCT + ART or NRT + ACT). Kaplan-Meier method estimated overall survival (OS). Proportional hazards model estimated OS hazard ratios for prognostic factors including age, comorbidity, gender, race, margin, histology, RT technique, RT dose, and CT type. Results: With a median follow-up of 34 months, the cohort included 2,298 male and 1,774 females with a median age of 61 years (range: 18-90). RT and CT were delivered in 2,567 and 1,228 patients reducing mortality hazards ratio (HR) 0.61 (95% confidence intervals (CIs) 0.54-0.68); and 0.65 (CI: 0.58-0.73), respectively, compared with surgery alone. The 5year OS was 36%, 58%, 59%, 49%, 56%, 55%, 52%, and 51% in SA, ACRT, NCRT, ACT, NCT, M, ART, and NRT, respectively. Timing of treatment intervention, either adjuvant or neoadjuvant, did not result in significant survival advantage. ACRT, NCRT, and M trended towards an improvement in survival compared to other approaches. There was a mortality HR reduction of 0.46 (CI: 0.39-0.55), 0.66 (CI: 0.53-0.84), and 0.60 (CI: 0.53-0.68) in combined modalities, when compared to CT alone and RT alone, respectively. On multivariate analysis, age older than 50 years, positive margins, higher Charlson comorbidity score, and surgery alone were significant predictors of poor outcome. Conclusion: Our analysis hints that combined modality approach leads to better survival in patients with large, high-grade sarcoma. Further studies are warranted to establish this paradigm as the standard of care. Author Disclosure: O.M. Mahmoud: None. A.S. Tunceroglu: None. J. Benevenia: None. B. Kathleen: None. F. Patterson: None. R. Chokshi: None. R.R. Parikh: None. K.M. Alektiar: None.
54 Multi-Institutional Soft Tissue Sarcoma Real-Time Peer Review Radiation Therapy Quality Assurance Rounds C.I. Dickie,1,2 B. O’Sullivan,3 A. Griffin,4 L. Morley,2 C.B. Falkson,5 J.A. Hammond,6 M.B. Sharpe,2 P. Chung,7 P. Ferguson,4 J. Wunder,8 D.B. Shultz,2 and C.N. Catton7; 1University of Toronto, Toronto, ON, Canada, 2Princess Margaret Cancer Centre, Toronto, ON, Canada, 3 Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, ON, Canada, 4Mount Sinai Hospital, Toronto, ON, Canada, 5Queen’s University, Kingston, ON, Canada, 6 London Health Sciences Centre, London, ON, Canada, 7Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada, 8Mt Sinai Hospital, University of Toronto, Toronto, ON, Canada Purpose/Objective(s): To determine the feasibility of multi-institutional Soft tissue sarcoma (STS) Real Time Radiotherapy Quality Assurance (RT QA) Rounds, standardize collected metrics and process, and report our initial experience on the efficiency and effectiveness of these rounds. Materials/Methods: Regional centers involved in multidisciplinary STS RT treatment were invited to attend biweekly RT QA rounds, which aligned with Provincial Sarcoma Services guidelines. Data was reviewed from July to December 2015. Real time review was conducted according to provincial privacy regulations using a tele-videoconferencing network approved by all participating institutions. Radical and complex palliative cases were discussed. Metrics collected include number of cases reviewed, timeliness of review, case complexity (follows protocol or highly individualized plan), intent/management, prescription, target volumes, Organs at Risk (OARs), pre-tx and on-tx imaging, DVHs, and RT plan. “Learning moments” were defined as significant discussion about an issue that led to improved team knowledge, standardization of practice, and/or contributed to practice improvement. Discussion included issues on practice/management, dose/fractionation, plan quality and DVHs, target volumes and RT technique. The group must approve or suggest minor/major plan adjustments, and reach a consensus for each case reviewed. Plan improvements were recorded. Results: Three large provincial centers consistently attend RTQA rounds. Seventy-two cases were presented during the study timeframe (75% of all cases). Seventy-four percent of cases were reviewed prior to RT or within one week from the onset of RT. The remainder were reviewed over one
Oral Scientific Sessions
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week from the start of RT. Table 1 summarizes peer review metrics discussed and ’Learning moments’. 4 plan adjustments have resulted; 3 CTV modifications and one addition of bolus. Abstract 54; Table 1 Peer review metrics Intent/Management Prescription Targets OARs Pre-tx Imaging On-Tx Imaging DVHs Plan LEARNING MOMENTS: Practice/management Dose/fractionation Plan Quality Target Volume Technique
% of cases discussed (radical and complex palliative) 92 100 100 99 93 1 99 97 29 54 32 51 34
Conclusion: Multi-institutional STS real time RTQA rounds increase the critical mass of specialists evaluating treatment plans for a rare disease. They are feasible and are now routine practice. Chosen quality metrics’ effectiveness was demonstrated by discussion in 92-100% of cases, excepting on-treatment imaging. ‘Learning moments’ discussion reflects successful knowledge translation and communication among centers engaged in this provincial initiative. 4 clinically important changes were made before the commencement of RT. Efficiency metrics are expected to improve with automated RTQA programs which are being explored. Author Disclosure: C.I. Dickie: None. B. O’Sullivan: None. A. Griffin: None. L. Morley: None. C.B. Falkson: None. J.A. Hammond: None. M.B. Sharpe: None. P. Chung: None. P. Ferguson: None. J. Wunder: None. D.B. Shultz: None. C.N. Catton: None.
55 Secondary Leukemia and Myelodysplastic Syndrome in 375 Patients With Ewing Sarcoma and Osteosarcoma N.N. Sanford,1 H. Wang,2 S. Goldberg,3 Y.L.E. Chen,2 A. Jacobson,2 E. Choy,4 G. Cote,3 T. Stanton,3 F.J. Hornicek,3 T.F. DeLaney,2 and D. Harmon3; 1Harvard Radiation Oncology Program, Boston, MA, 2 Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, 3Massachusetts General Hospital, Boston, MA, 4Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA Purpose/Objective(s): Outcomes in patients with Ewing sarcoma (ES) and osteosarcoma have improved due to refinements in surgical techniques, radiotherapy (RT), and chemotherapy. There is concern however that survivors are at increasing risk of secondary leukemia (SL) or myelodysplastic syndrome (MDS). Materials/Methods: We retrospectively reviewed the clinicopathologic and treatment details of 375 patients with osteosarcoma (250) and ES (125) treated at our institution from January 1999 to July 2014. Cumulative incidence (CI) of SL/MDS was estimated using completing risk analysis. Overall survival (OS) was estimated using the Kaplan-Meier method and Cox proportional hazards regression was used to analyze predictors for SL/ MDS development. Results: The median age of the entire cohort at diagnosis was 25 years (range 0 - 87) and 42.9% of patients were female. Seventy-nine percent were treated for non-metastatic disease. The primary sites of disease were 40.3% lower extremity, 21.9% pelvis, and 6.7% spine. Local treatment included surgery alone in 48.3%, surgery and RT in 27.7%, and RT alone in 17.9%. Of the 172 (45.6%) of patients receiving RT, 94 (54.6%) was with protons. Eighty-two percent were treated with chemotherapy. After a median follow up time of 3.8 years (range 0 - 16.8) and 5.2 years for 224 survivors (0.4 e 16.8), OS for ES was 60.7% and 48.7% at 5 and 10 years, respectively, and for osteosarcoma was 72.5% at 5 years and 61.9% at 10
54 Multi-Institutional Soft Tissue Sarcoma Real-Time Peer Review Radiation Therapy Quality Assurance Rounds C.I. Dickie,1,2 B. O’Sullivan,3 A. Griffin,4 L. Morley,2 C.B. Falkson,5 J.A. Hammond,6 M.B. Sharpe,2 P. Chung,7 P. Ferguson,4 J. Wunder,8 D.B. Shultz,2 and C.N. Catton7; 1University of Toronto, Toronto, ON, Canada, 2Princess Margaret Cancer Centre, Toronto, ON, Canada, 3 Department of Radiation Oncology, Princess Margaret Cancer Centre / University of Toronto, Toronto, ON, Canada, 4Mount Sinai Hospital, Toronto, ON, Canada, 5Queen’s University, Kingston, ON, Canada, 6 London Health Sciences Centre, London, ON, Canada, 7Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada, 8Mt Sinai Hospital, University of Toronto, Toronto, ON, Canada Purpose/Objective(s): To determine the feasibility of multi-institutional Soft tissue sarcoma (STS) Real Time Radiotherapy Quality Assurance (RT QA) Rounds, standardize collected metrics and process, and report our initial experience on the efficiency and effectiveness of these rounds. Materials/Methods: Regional centers involved in multidisciplinary STS RT treatment were invited to attend biweekly RT QA rounds, which aligned with Provincial Sarcoma Services guidelines. Data was reviewed from July to December 2015. Real time review was conducted according to provincial privacy regulations using a tele-videoconferencing network approved by all participating institutions. Radical and complex palliative cases were discussed. Metrics collected include number of cases reviewed, timeliness of review, case complexity (follows protocol or highly individualized plan), intent/management, prescription, target volumes, Organs at Risk (OARs), pre-tx and on-tx imaging, DVHs, and RT plan. “Learning moments” were defined as significant discussion about an issue that led to improved team knowledge, standardization of practice, and/or contributed to practice improvement. Discussion included issues on practice/management, dose/fractionation, plan quality and DVHs, target volumes and RT technique. The group must approve or suggest minor/major plan adjustments, and reach a consensus for each case reviewed. Plan improvements were recorded. Results: Three large provincial centers consistently attend RTQA rounds. Seventy-two cases were presented during the study timeframe (75% of all cases). Seventy-four percent of cases were reviewed prior to RT or within one week from the onset of RT. The remainder were reviewed over one
Oral Scientific Sessions
S25
week from the start of RT. Table 1 summarizes peer review metrics discussed and ’Learning moments’. 4 plan adjustments have resulted; 3 CTV modifications and one addition of bolus. Abstract 54; Table 1 Peer review metrics Intent/Management Prescription Targets OARs Pre-tx Imaging On-Tx Imaging DVHs Plan LEARNING MOMENTS: Practice/management Dose/fractionation Plan Quality Target Volume Technique
% of cases discussed (radical and complex palliative) 92 100 100 99 93 1 99 97 29 54 32 51 34
Conclusion: Multi-institutional STS real time RTQA rounds increase the critical mass of specialists evaluating treatment plans for a rare disease. They are feasible and are now routine practice. Chosen quality metrics’ effectiveness was demonstrated by discussion in 92-100% of cases, excepting on-treatment imaging. ‘Learning moments’ discussion reflects successful knowledge translation and communication among centers engaged in this provincial initiative. 4 clinically important changes were made before the commencement of RT. Efficiency metrics are expected to improve with automated RTQA programs which are being explored. Author Disclosure: C.I. Dickie: None. B. O’Sullivan: None. A. Griffin: None. L. Morley: None. C.B. Falkson: None. J.A. Hammond: None. M.B. Sharpe: None. P. Chung: None. P. Ferguson: None. J. Wunder: None. D.B. Shultz: None. C.N. Catton: None.
55 Secondary Leukemia and Myelodysplastic Syndrome in 375 Patients With Ewing Sarcoma and Osteosarcoma N.N. Sanford,1 H. Wang,2 S. Goldberg,3 Y.L.E. Chen,2 A. Jacobson,2 E. Choy,4 G. Cote,3 T. Stanton,3 F.J. Hornicek,3 T.F. DeLaney,2 and D. Harmon3; 1Harvard Radiation Oncology Program, Boston, MA, 2 Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, 3Massachusetts General Hospital, Boston, MA, 4Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA Purpose/Objective(s): Outcomes in patients with Ewing sarcoma (ES) and osteosarcoma have improved due to refinements in surgical techniques, radiotherapy (RT), and chemotherapy. There is concern however that survivors are at increasing risk of secondary leukemia (SL) or myelodysplastic syndrome (MDS). Materials/Methods: We retrospectively reviewed the clinicopathologic and treatment details of 375 patients with osteosarcoma (250) and ES (125) treated at our institution from January 1999 to July 2014. Cumulative incidence (CI) of SL/MDS was estimated using completing risk analysis. Overall survival (OS) was estimated using the Kaplan-Meier method and Cox proportional hazards regression was used to analyze predictors for SL/ MDS development. Results: The median age of the entire cohort at diagnosis was 25 years (range 0 - 87) and 42.9% of patients were female. Seventy-nine percent were treated for non-metastatic disease. The primary sites of disease were 40.3% lower extremity, 21.9% pelvis, and 6.7% spine. Local treatment included surgery alone in 48.3%, surgery and RT in 27.7%, and RT alone in 17.9%. Of the 172 (45.6%) of patients receiving RT, 94 (54.6%) was with protons. Eighty-two percent were treated with chemotherapy. After a median follow up time of 3.8 years (range 0 - 16.8) and 5.2 years for 224 survivors (0.4 e 16.8), OS for ES was 60.7% and 48.7% at 5 and 10 years, respectively, and for osteosarcoma was 72.5% at 5 years and 61.9% at 10