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Pattern of care in high-grade gliomas after recurrence
abstracts
Annals of Oncology 57P
Multidisciplinary brain metastasis clinic: Is it effective and worthwhile?
Background: Management of brain metastasis is a complex multidisciplinary venture. Hence, we started a multidisciplinary brain metastasis clinic for opinion on difficult brain metastasis cases. This is the review of the impact of this clinic on the treatment decisions. Methods: Brain metastasis clinic (BMC) was started in the month of April 2018 and meets once a week. Data of patients discussed between 27th April 2018 to 28th June 2019 were included for thisanalysis. Treatment decision made by clinicians (before sending the patient to the BMC were compared with the decisions made in BMC. The decisions were broken on a predefined proforma as intent of treatment (curative or palliative), modalities planned (surgery, radiation, chemotherapy), type of therapy planned (details of each therapy) in each modality were collected both pre and post BMC. In addition, compliance of the respective physicians to BMC decision was also calculated. SPSS version 20 was used for analysis. Descriptive statistics was performed. Results: Ninety-nine patients were discussed in this time period. The median age was 51 (range 17-68) years. The gender distribution was 70 males (70.7%) and 29 females (29.3%). Lung was thepredominant site of malignancy (79, 79.8%). Thirty-one patients (31.3%) had EGFR TKI domain activating mutation while 17 (17.2%) had ALK rearrangement. The treatment plan was changed in 46 patients (46.5%). The intent of treatment was changed in 5 patients (5.3%). Change in treatment plan with respect to surgery in 9 patients (9.1%), radiation in 37 patients (37.4%), chemotherapy in 15 patients (15.2%), targeted therapy in 11 patients (22.9%) and intrathecal in 6 patients (6.1%) respectively. The compliance to the BMC decision in patients in whom it was changed was 84.8% (39, n ¼ 46). Conclusions: Multidisciplinary management of difficult brain metastasis cases in specialized clinics has significant impact on treatment decisions. Legal entity responsible for the study: Tata Memorial Hospital, Mumbai. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
N. Menon1, V. Simha1, A. Abhyankar2, D. Kalra1, R. Krishnatry3, T. Gupta3, R. Jalali3, V.M. Patil1 1 Medical Oncology, Tata Memorial Hospital, Mumbai, India, 2Medicine, JJ Hospital, Mumbai, India, 3Radiation Oncology, Tata Memorial Hospital, Mumbai, India Background: Relapse or progression in glioblastoma is common. Multiple options ranging from local treatment like re-surgery, re-radiation to systemic therapies like bevacizumab, CCNU, etc. are available. Patients with longer progression-free interval (> 2 years), smaller volume of disease and disease in non-eloquent areas are preferably selected for local therapies and while the others receive systemic therapy. There is limited data available on the pattern of care in relapsed gliomas hence we conducted an audit to address this deficiency. Methods: A prospective database of all glioma patients has been maintained from June 2015 onwards at neuro-oncology DMG (Disease Management Group) at the Tata Memorial Hospital. We analysed the data of patients with relapsed gliomas treated from June 2015 to December 2017. Results: The database had 854 patients of which 749 (87.7%) had disease progression. The treatment received by these 749 patients were best supportive care in 519 (69.3%), local therapy with or without systemic therapy in 85 (11.3%) and systemic therapy in 145 (19.4%) patients. Local therapy consisted of re-surgery (with or without re-radiation) in 63 patients and re-radiation (with or without systemic therapy) in 23 patients. The systemic therapies received were salvage temozolomide in 79 patients, bevacizumab (with or without an additional agent) in 41 patients and CCNU in 25 patients. The factors associated with administration of therapy at relapse were age (p ¼ 0.009) and family income (0.041). The other factors tested were gender (p ¼ 0.311) and performance status at relapse (p ¼ 0.637). Conclusions: This data highlights that a large number of patients with recurrent gliomas do not receive any treatment (69%), which is similar to the pattern of care reported from Australia. The pessimism associated with treatment of relapsed glioma is due to dismal prognosis at relapse with the current therapy available. Legal entity responsible for the study: Tata Memorial Hospital. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
60P 58P
Functional status as a determinant prognostic factor for overall survival in adult patients with medulloblastoma treated with chemotherapy and radiotherapy
J.C. Ayala Alvarez, R.R. Trejo Rosales, R. Riera Salas, M.F. Chilaca Rosas, S. Rivera Rivera, J.C. Silva Godinez, B.A. Salvador Bonilla Medical Oncology, Instituto Mexicano del Seguro Social, Mexico City, Mexico Background: Medulloblastomas are a rare disease in adult population. Currently the main treatment consists in surgical resection. There is a lack of prospective evidence and the adequate regimen of chemotherapy and radiotherapy is yet to be defined. Methods: We conducted a retrospective study including adult patients with medulloblastoma treated at a tertiary referral center. The aim of this study was to estimate Overall survival (OS) and disease-free survival (DFS). Results: We identified a total of 58 patients. Median age was 28 years (range 16 – 62). A total of 26 patients, (44%) received at least one chemotherapy regimen. The most frequent combination was Vincristine/Cisplatin/Cyclophosphamide (VPC) (29%). 43% were treated with a concomitant chemoradiotherapy. DFS was 35.5 months, (range 4100 months). Patients who underwent partial tumor removal presented 62-month OS. Patients with total resection surgery did not reach median OS (HR 1.98, CI 0.67 – 5.8). Those treated with chemotherapy did not reach OS. Patients without chemotherapy regimen have 62-month OS (HR 0.6 CI 0.19 – 1.8) Patients treated with VPC did not meet median overall survival, meanwhile other regimen implementations demonstrated 43-month OS (HR 2.00 CI 0.71 – 5.62) (p ¼ 0.18). Patients who were nt treated with chemoradiotherapy did not reach OS vs patients treated with sequential radiotherapy and chemotherapy (HR 0.65, CI 0.21 – 1.99) (P 0.45). Performance status was an important predictor of OS, patients with ECOG 3 demonstrated 12 months of OS meanwhile patients with ECOG 0 – 2 did not reach a median OS (HR 2.7, CI 1.63 – 4.55). Related to adverse events, 16% of patients treated with chemotherapy presented grade 3 and 4 toxicity. 10% of these patients manifested grade 3 or 4 neutropenia. A total of 51 pts (88%) received radiotherapy. 22 patients developed radioepithelitis (38%) and 13 pts developed radiotherapy-associated CNS toxicity. Conclusions: In this study of 58 adult patients diagnosed with Medulloblastoma the results showed a performance status as an important OS prognostic factor. Sequential chemotherapy or concomitant therapy did not show an OS significance probably related to the size of our population. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
Volume 30 | Supplement 9 | November 2019
Pattern of care in high-grade gliomas after recurrence
Five fractions plus “SRS” boost combined with temozolamide for newly diagnosed and recurrent glioblastoma multiforme (GBM)
A. Rashid1, M.A. Memon1, A.S.M. Hashim2 Clinical Oncology, Neurospinal & Cancer Care Institute (NCCI), Karachi, Pakistan, 2 Neurosurgery, Neurospinal & Cancer Care Institute (NCCI), Karachi, Pakistan
1
Background: The studies on hypo-fractionation for GBM showed 5-12 months median overall survivals not inferior to standard fractionation protocols. We aimed to describe the feasibility of extreme hypo fractionation combined with temozolamide for newly diagnosed and recurrent GBM. Methods: During Dec 2015- Dec 2017, 60 patients of biopsy proven GBM were retrospectively scrutinized and were analysed. PTV was defined on FLAIR/T2 signal coverage with 4 mm margin and GTV was defined as contrast enhanced tumor. PTV was prescribed with 5 Gy (range: 4.5-6 Gy) in five fractions at isocenter and GTV was prescribed as single fraction SRS as 8 Gy (range: 6-12 Gy) at 75% (range: 65-90%) isodose line. Radiation was completed in 8 days. Temozolamide was given as 100mg daily for 8 days. Results: Mean age was 45 years (range: 22- 74 years). 40(66.66%) patients were male and 20(33.33%) were female. CR was found in 07 (11.66%) patients, PR was seen in 28 (46.66%) patients. SD was observed in 20 (33.33%) patients. 05 (8.33%) had PD during first 3-4 months. Treatment was tolerated very well. Only 5 patients used corticosteroids for 3 months. Median follow-up time was 24 months (range: 08-32 months). Median survival in newly diagnosed patients was 12.5 months (range: 4.5 -16 months), while in recurrent cases it was 8.5 months (range: 3 -11 months). Conclusions: Extreme hypo-fractionation combined with temozolamide is safe and an effective approach to manage GBM cases and survivals are also comparable to the standard approaches. Further randomized studies are warranted to establish its regular use. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
doi:10.1093/annonc/mdz419 | ix21
Downloaded from https://academic.oup.com/annonc/article-abstract/30/Supplement_9/mdz419.006/5638349 by University of Winnipeg user on 28 November 2019
A. Rajpurohit1, V.M. Patil1, V. Noronha1, A. Joshi1, N. Menon1, A. Puranik2, N. Purandare2, A. Mahajan3, N. Mummudi4, R. Krishnatry4, R. Kumar5, S. Yadav5, K. Prabhash1 1 Medical Oncology, Tata Memorial Hospital, Mumbai, India, 2Nuclear Medicine, Tata Memorial Hospital, Mumbai, India, 3Radiology, Tata Memorial Hospital, Mumbai, India, 4 Radiation Oncology, Tata Memorial Hospital, Mumbai, India, 5Pathology, Tata Memorial Hospital, Mumbai, India
59P
Annals of Oncology 57P
Multidisciplinary brain metastasis clinic: Is it effective and worthwhile?
Background: Management of brain metastasis is a complex multidisciplinary venture. Hence, we started a multidisciplinary brain metastasis clinic for opinion on difficult brain metastasis cases. This is the review of the impact of this clinic on the treatment decisions. Methods: Brain metastasis clinic (BMC) was started in the month of April 2018 and meets once a week. Data of patients discussed between 27th April 2018 to 28th June 2019 were included for thisanalysis. Treatment decision made by clinicians (before sending the patient to the BMC were compared with the decisions made in BMC. The decisions were broken on a predefined proforma as intent of treatment (curative or palliative), modalities planned (surgery, radiation, chemotherapy), type of therapy planned (details of each therapy) in each modality were collected both pre and post BMC. In addition, compliance of the respective physicians to BMC decision was also calculated. SPSS version 20 was used for analysis. Descriptive statistics was performed. Results: Ninety-nine patients were discussed in this time period. The median age was 51 (range 17-68) years. The gender distribution was 70 males (70.7%) and 29 females (29.3%). Lung was thepredominant site of malignancy (79, 79.8%). Thirty-one patients (31.3%) had EGFR TKI domain activating mutation while 17 (17.2%) had ALK rearrangement. The treatment plan was changed in 46 patients (46.5%). The intent of treatment was changed in 5 patients (5.3%). Change in treatment plan with respect to surgery in 9 patients (9.1%), radiation in 37 patients (37.4%), chemotherapy in 15 patients (15.2%), targeted therapy in 11 patients (22.9%) and intrathecal in 6 patients (6.1%) respectively. The compliance to the BMC decision in patients in whom it was changed was 84.8% (39, n ¼ 46). Conclusions: Multidisciplinary management of difficult brain metastasis cases in specialized clinics has significant impact on treatment decisions. Legal entity responsible for the study: Tata Memorial Hospital, Mumbai. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
N. Menon1, V. Simha1, A. Abhyankar2, D. Kalra1, R. Krishnatry3, T. Gupta3, R. Jalali3, V.M. Patil1 1 Medical Oncology, Tata Memorial Hospital, Mumbai, India, 2Medicine, JJ Hospital, Mumbai, India, 3Radiation Oncology, Tata Memorial Hospital, Mumbai, India Background: Relapse or progression in glioblastoma is common. Multiple options ranging from local treatment like re-surgery, re-radiation to systemic therapies like bevacizumab, CCNU, etc. are available. Patients with longer progression-free interval (> 2 years), smaller volume of disease and disease in non-eloquent areas are preferably selected for local therapies and while the others receive systemic therapy. There is limited data available on the pattern of care in relapsed gliomas hence we conducted an audit to address this deficiency. Methods: A prospective database of all glioma patients has been maintained from June 2015 onwards at neuro-oncology DMG (Disease Management Group) at the Tata Memorial Hospital. We analysed the data of patients with relapsed gliomas treated from June 2015 to December 2017. Results: The database had 854 patients of which 749 (87.7%) had disease progression. The treatment received by these 749 patients were best supportive care in 519 (69.3%), local therapy with or without systemic therapy in 85 (11.3%) and systemic therapy in 145 (19.4%) patients. Local therapy consisted of re-surgery (with or without re-radiation) in 63 patients and re-radiation (with or without systemic therapy) in 23 patients. The systemic therapies received were salvage temozolomide in 79 patients, bevacizumab (with or without an additional agent) in 41 patients and CCNU in 25 patients. The factors associated with administration of therapy at relapse were age (p ¼ 0.009) and family income (0.041). The other factors tested were gender (p ¼ 0.311) and performance status at relapse (p ¼ 0.637). Conclusions: This data highlights that a large number of patients with recurrent gliomas do not receive any treatment (69%), which is similar to the pattern of care reported from Australia. The pessimism associated with treatment of relapsed glioma is due to dismal prognosis at relapse with the current therapy available. Legal entity responsible for the study: Tata Memorial Hospital. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
60P 58P
Functional status as a determinant prognostic factor for overall survival in adult patients with medulloblastoma treated with chemotherapy and radiotherapy
J.C. Ayala Alvarez, R.R. Trejo Rosales, R. Riera Salas, M.F. Chilaca Rosas, S. Rivera Rivera, J.C. Silva Godinez, B.A. Salvador Bonilla Medical Oncology, Instituto Mexicano del Seguro Social, Mexico City, Mexico Background: Medulloblastomas are a rare disease in adult population. Currently the main treatment consists in surgical resection. There is a lack of prospective evidence and the adequate regimen of chemotherapy and radiotherapy is yet to be defined. Methods: We conducted a retrospective study including adult patients with medulloblastoma treated at a tertiary referral center. The aim of this study was to estimate Overall survival (OS) and disease-free survival (DFS). Results: We identified a total of 58 patients. Median age was 28 years (range 16 – 62). A total of 26 patients, (44%) received at least one chemotherapy regimen. The most frequent combination was Vincristine/Cisplatin/Cyclophosphamide (VPC) (29%). 43% were treated with a concomitant chemoradiotherapy. DFS was 35.5 months, (range 4100 months). Patients who underwent partial tumor removal presented 62-month OS. Patients with total resection surgery did not reach median OS (HR 1.98, CI 0.67 – 5.8). Those treated with chemotherapy did not reach OS. Patients without chemotherapy regimen have 62-month OS (HR 0.6 CI 0.19 – 1.8) Patients treated with VPC did not meet median overall survival, meanwhile other regimen implementations demonstrated 43-month OS (HR 2.00 CI 0.71 – 5.62) (p ¼ 0.18). Patients who were nt treated with chemoradiotherapy did not reach OS vs patients treated with sequential radiotherapy and chemotherapy (HR 0.65, CI 0.21 – 1.99) (P 0.45). Performance status was an important predictor of OS, patients with ECOG 3 demonstrated 12 months of OS meanwhile patients with ECOG 0 – 2 did not reach a median OS (HR 2.7, CI 1.63 – 4.55). Related to adverse events, 16% of patients treated with chemotherapy presented grade 3 and 4 toxicity. 10% of these patients manifested grade 3 or 4 neutropenia. A total of 51 pts (88%) received radiotherapy. 22 patients developed radioepithelitis (38%) and 13 pts developed radiotherapy-associated CNS toxicity. Conclusions: In this study of 58 adult patients diagnosed with Medulloblastoma the results showed a performance status as an important OS prognostic factor. Sequential chemotherapy or concomitant therapy did not show an OS significance probably related to the size of our population. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
Volume 30 | Supplement 9 | November 2019
Pattern of care in high-grade gliomas after recurrence
Five fractions plus “SRS” boost combined with temozolamide for newly diagnosed and recurrent glioblastoma multiforme (GBM)
A. Rashid1, M.A. Memon1, A.S.M. Hashim2 Clinical Oncology, Neurospinal & Cancer Care Institute (NCCI), Karachi, Pakistan, 2 Neurosurgery, Neurospinal & Cancer Care Institute (NCCI), Karachi, Pakistan
1
Background: The studies on hypo-fractionation for GBM showed 5-12 months median overall survivals not inferior to standard fractionation protocols. We aimed to describe the feasibility of extreme hypo fractionation combined with temozolamide for newly diagnosed and recurrent GBM. Methods: During Dec 2015- Dec 2017, 60 patients of biopsy proven GBM were retrospectively scrutinized and were analysed. PTV was defined on FLAIR/T2 signal coverage with 4 mm margin and GTV was defined as contrast enhanced tumor. PTV was prescribed with 5 Gy (range: 4.5-6 Gy) in five fractions at isocenter and GTV was prescribed as single fraction SRS as 8 Gy (range: 6-12 Gy) at 75% (range: 65-90%) isodose line. Radiation was completed in 8 days. Temozolamide was given as 100mg daily for 8 days. Results: Mean age was 45 years (range: 22- 74 years). 40(66.66%) patients were male and 20(33.33%) were female. CR was found in 07 (11.66%) patients, PR was seen in 28 (46.66%) patients. SD was observed in 20 (33.33%) patients. 05 (8.33%) had PD during first 3-4 months. Treatment was tolerated very well. Only 5 patients used corticosteroids for 3 months. Median follow-up time was 24 months (range: 08-32 months). Median survival in newly diagnosed patients was 12.5 months (range: 4.5 -16 months), while in recurrent cases it was 8.5 months (range: 3 -11 months). Conclusions: Extreme hypo-fractionation combined with temozolamide is safe and an effective approach to manage GBM cases and survivals are also comparable to the standard approaches. Further randomized studies are warranted to establish its regular use. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.
doi:10.1093/annonc/mdz419 | ix21
Downloaded from https://academic.oup.com/annonc/article-abstract/30/Supplement_9/mdz419.006/5638349 by University of Winnipeg user on 28 November 2019
A. Rajpurohit1, V.M. Patil1, V. Noronha1, A. Joshi1, N. Menon1, A. Puranik2, N. Purandare2, A. Mahajan3, N. Mummudi4, R. Krishnatry4, R. Kumar5, S. Yadav5, K. Prabhash1 1 Medical Oncology, Tata Memorial Hospital, Mumbai, India, 2Nuclear Medicine, Tata Memorial Hospital, Mumbai, India, 3Radiology, Tata Memorial Hospital, Mumbai, India, 4 Radiation Oncology, Tata Memorial Hospital, Mumbai, India, 5Pathology, Tata Memorial Hospital, Mumbai, India
59P