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Pretreatment SUVmax on [18F]FDG-PET Is Associated With Recurrence and Survival After SBRT for Early-Stage NSCLC
S12
International Journal of Radiation Oncology Biology Physics
PET was available in 98% and median pre-SBRT SUVm was 4.8. PostSBRT PET was performed in 33% and median post-SBRT SUVm was 2.3. SUVm declined by a median of 3.7 units post-SBRT. There were 5, 4, and 12 local, regional, and distant failures, respectively. On multivariate analysis, older age, tumor size, and squamous histology predicted for higher rates of any failure (p Z 0.034, < 0.001, 0.016, respectively). Conversely, larger absolute reduction in SUVm post-SBRT predicted for improved rates of disease control (p Z 0.005). Median OS was 14.65 months. On multivariate Cox proportional hazards analysis of predictors of overall survival, higher pre-SBRT SUVm, larger size, squamous cell histology, and staging mediastinoscopy predicted for worse OS (all p < 0.05). Conclusions: PET is a powerful tool in the work-up of newly diagnosed NSCLC. SUVm values appear to also have prognostic importance, as absolute change in SUVm after SBRT predicts for failure and pre-SBRT SUVm predicts for overall survival. Author Disclosure: B.R. Mancini: None. N.J. Giacalone: None. C.E. Rutter: None. S. Aneja: None. R.H. Decker: None. Z.A. Husain: None.
stage (HR 2.85, p Z 0.009) and non-adenocarcinoma histology (HR 2.21, p Z 0.042) were. Conclusions: Our results demonstrate that pre-treatment SUVmax is strongly associated with survival and recurrence after SBRT. This suggests that pre-treatment SUVmax may be a useful prognostic tool in patients undergoing SBRT and that tumors with high SUVmax may achieve improved outcomes with intensified or adjuvant therapy. Author Disclosure: Z. Kohutek: None. A.J. Wu: None. Z. Zhang: None. S. Din: None. A. Foster: None. E. Yorke: None. K.E. Rosenzweig: None. R. Downey: None. A. Rimner: G. Consultant; GE.
27 Pretreatment SUVmax on [18F]FDG-PET Is Associated With Recurrence and Survival After SBRT for Early-Stage NSCLC Z. Kohutek,1 A.J. Wu,1 Z. Zhang,1 S. Din,1 A. Foster,1 E. Yorke,1 K.E. Rosenzweig,2 R. Downey,1 and A. Rimner1; 1Memorial SloanKettering Cancer Center, New York, NY, 2Mount Sinai Medical Center, New York, NY Purpose/Objective(s): Pre-treatment maximum standardized uptake value (SUVmax) on 18F-fluorodeoxyglucose positron emission tomography ([18F]FDG-PET) correlates with survival in surgically managed patients with early-stage non-small cell lung cancer (NSCLC), but its value in patients treated with stereotactic body radiation therapy (SBRT) remains unclear. We sought to investigate the prognostic impact of pre-treatment SUVmax in patients with NSCLC treated with SBRT. Materials/Methods: Two hundred thirty-six patients with 249 biopsyproven T1-2N0M0 NSCLCs treated with SBRT at our institution from August 2006 to August 2012 were included. Patients with recurrent tumors, prior in-field RT, neoadjuvant chemotherapy, fewer than 3 months of follow-up, or lack of PET imaging within 9 months of RT were excluded. Local failure (LF), nodal failure (NF), distant failure (DF) and overall survival (OS) were estimated by the Kaplan-Meier method and compared using the log-rank test. Disease specific mortality (DSM) was analyzed using competing risk analysis with death from other causes as a competing risk. A univariate analysis (UVA) was performed using age, gender, KPS, T stage, histology, biologically equivalent dose using an alpha/beta of 10 (< vs 100 Gy) and SUVmax on pre-treatment PET ( vs > median SUVmax). All significant variables were included in a multivariate analysis (MVA), using competing risk for DSM and Cox regression for all other endpoints. Results: Median follow-up among survivors was 21 months (range, 3 - 63). Median time from pre-treatment PET to SBRT was 1.8 months (range, 0.1 - 8.1) and median SUVmax was 4.6 (range, 0.6 - 28.4). Twentyseven local, 29 nodal and 41 distant failures were observed. There were 39 disease-related deaths and 64 deaths from other causes. On UVA, SUVmax was significantly associated with all examined endpoints. Tumors with SUVmax > 4.6 had significantly increased 2-year rates of LF (21.1% vs 8.5%, p Z 0.03), NF (25.5% vs 8.2%, p Z 0.001), DF (29.7% vs 11.3%, p Z 0.001) and DSM (19.3% vs 4.1%, p Z 0.002), as well as decreased 2-year OS (59.0% vs 81.2%, p < 0.001). On MVA, SUVmax (HR 1.78, p Z 0.007), KPS (HR 0.97, p < 0.001), age (HR 1.03, p Z 0.046) and male gender (HR 1.65, p Z 0.017) were significantly associated with worse OS. SUVmax was the only variable associated with DSM (HR 2.80, p Z 0.003) and DF (HR 2.79, p Z 0.002). NF was associated with SUVmax (HR 3.12, p Z 0.007) and male gender (HR 2.55, p Z 0.017). SUVmax was not associated with LF, while T
28 Tumoricidal Robotic Radiation: 96% 2-Year Disease-Specific Survival Following Robotic Radiosurgery Stereotactic Body Radiation Therapy for Early Stage Non-Small Cell Lung Cancer H. Bahig,1 E. Filion,1 T. Vu,1 D. Roberge,1 L. Lambert,1 M. Bouchard,2 C. Lavoie,3 R. Doucet,1 D. Be´liveau-Nadeau,1 and M. Campeau1; 1Centre Hospitalier de l’Universite´ de Montre´al, Notre-Dame Hospital, Montreal, QC, Canada, 2Centre Hospitalier Universitaire de Sherbrooke, Montreal, QC, Canada, 3Centre Hospitalier Universitaire de Quebec, Montreal, QC, Canada Purpose/Objective(s): The robotic radiosurgery system allows for precise stereotactic body radiation therapy (SBRT) delivery using near real time in-treatment tracking. In this study, we report our local control, survival and toxicity results for early stage non-small cell lung cancer (NSCLC) treated with robotic radiosurgery SBRT. Materials/Methods: A retrospective analysis of the first 130 out of 200 patients with T1-2N0 NSCLC treated between July 2009 and December 2011 was conducted. Median age was 75 (range, 55-95). Eighty-two percent of patients were medically inoperable and 18% had declined surgery. Median Charlson comorbidity index was 4 (range, 2-14). Work-up included diagnostic CT-scan and TEP scan for all patients; 83% had histological diagnosis. Median tumor size was 2.5 cm (range, 1.1 -4.7 cm), with 82% T1N0 and 18% T2N0. Thirty-three (25%) tumors were central. SBRT was delivered using direct soft tissue tracking in 46 (35%) patients, fiducials in 60 (46%) patients and tracking of adjacent bone in 26 (20%) patients. Median delivered dose was 60 Gy in 3 fractions (uncorrected for tissue inhomogeneity, median biological equivalent dose of 180 Gy, a/b Z 10). Kaplan Meier and Cox proportional hazard ratio models were used for local control and survival analysis. Tumor response were defined as per RECIST criteria v1.1 and based on CT-scans. Toxicities were graded as per CTCAE v3.0. Results: Median follow-up was 20 months. The actuarial 2 years local control (LC), overall survival and disease-specific survival were respectively 93%, 87% and 96%. Local relapse was observed in 7 (5%) patients, regional relapse in 3 (2%) patients and distant relapse in 16 (12%) patients. Every 1 cm increase in tumor diameter was associated with a relative risk (RR) for regional or distant relapse of 2 (95% CI Z 1.2-3.6, p Z 0.009). The adjusted RR for death in patients receiving doses below 60 Gy in 5 fractions (biological equivalent dose < 132 Gy, a/b Z 10) was 3 (95% CI Z 1.25 - 10.4, p Z 0.02). Complete response, partial response and stable disease were observed in 33 (25%), 48 (37%) and 23 (18%) patients, respectively. Two patients with idiopathic pulmonary fibrosis developed grade 5 pneumonitis. Monte Carlo lung V5, V20 and mean dose were 33%, 16%, 8.1 Gy for the first patient and 48%, 21% and 10.6 Gy for the second patient. Toxicities otherwise included 2 patients with grade 3 pneumonitis, 8 patients (6%) with grade 2 costal tenderness and 5 patients (4%) with rib fractures. Conclusions: Excellent LC was obtained with robotic radiosurgery lung SBRT. In general, toxicities were minimal but patients with pulmonary fibrosis could be at risk of severe complications. Smaller tumors and BED > 132 Gy were associated with better outcomes. Author Disclosure: H. Bahig: None. E. Filion: None. T. Vu: None. D. Roberge: None. L. Lambert: None. M. Bouchard: None. C. Lavoie: None. R. Doucet: None. D. Be´liveau-Nadeau: None. M. Campeau: None.
International Journal of Radiation Oncology Biology Physics
PET was available in 98% and median pre-SBRT SUVm was 4.8. PostSBRT PET was performed in 33% and median post-SBRT SUVm was 2.3. SUVm declined by a median of 3.7 units post-SBRT. There were 5, 4, and 12 local, regional, and distant failures, respectively. On multivariate analysis, older age, tumor size, and squamous histology predicted for higher rates of any failure (p Z 0.034, < 0.001, 0.016, respectively). Conversely, larger absolute reduction in SUVm post-SBRT predicted for improved rates of disease control (p Z 0.005). Median OS was 14.65 months. On multivariate Cox proportional hazards analysis of predictors of overall survival, higher pre-SBRT SUVm, larger size, squamous cell histology, and staging mediastinoscopy predicted for worse OS (all p < 0.05). Conclusions: PET is a powerful tool in the work-up of newly diagnosed NSCLC. SUVm values appear to also have prognostic importance, as absolute change in SUVm after SBRT predicts for failure and pre-SBRT SUVm predicts for overall survival. Author Disclosure: B.R. Mancini: None. N.J. Giacalone: None. C.E. Rutter: None. S. Aneja: None. R.H. Decker: None. Z.A. Husain: None.
stage (HR 2.85, p Z 0.009) and non-adenocarcinoma histology (HR 2.21, p Z 0.042) were. Conclusions: Our results demonstrate that pre-treatment SUVmax is strongly associated with survival and recurrence after SBRT. This suggests that pre-treatment SUVmax may be a useful prognostic tool in patients undergoing SBRT and that tumors with high SUVmax may achieve improved outcomes with intensified or adjuvant therapy. Author Disclosure: Z. Kohutek: None. A.J. Wu: None. Z. Zhang: None. S. Din: None. A. Foster: None. E. Yorke: None. K.E. Rosenzweig: None. R. Downey: None. A. Rimner: G. Consultant; GE.
27 Pretreatment SUVmax on [18F]FDG-PET Is Associated With Recurrence and Survival After SBRT for Early-Stage NSCLC Z. Kohutek,1 A.J. Wu,1 Z. Zhang,1 S. Din,1 A. Foster,1 E. Yorke,1 K.E. Rosenzweig,2 R. Downey,1 and A. Rimner1; 1Memorial SloanKettering Cancer Center, New York, NY, 2Mount Sinai Medical Center, New York, NY Purpose/Objective(s): Pre-treatment maximum standardized uptake value (SUVmax) on 18F-fluorodeoxyglucose positron emission tomography ([18F]FDG-PET) correlates with survival in surgically managed patients with early-stage non-small cell lung cancer (NSCLC), but its value in patients treated with stereotactic body radiation therapy (SBRT) remains unclear. We sought to investigate the prognostic impact of pre-treatment SUVmax in patients with NSCLC treated with SBRT. Materials/Methods: Two hundred thirty-six patients with 249 biopsyproven T1-2N0M0 NSCLCs treated with SBRT at our institution from August 2006 to August 2012 were included. Patients with recurrent tumors, prior in-field RT, neoadjuvant chemotherapy, fewer than 3 months of follow-up, or lack of PET imaging within 9 months of RT were excluded. Local failure (LF), nodal failure (NF), distant failure (DF) and overall survival (OS) were estimated by the Kaplan-Meier method and compared using the log-rank test. Disease specific mortality (DSM) was analyzed using competing risk analysis with death from other causes as a competing risk. A univariate analysis (UVA) was performed using age, gender, KPS, T stage, histology, biologically equivalent dose using an alpha/beta of 10 (< vs 100 Gy) and SUVmax on pre-treatment PET ( vs > median SUVmax). All significant variables were included in a multivariate analysis (MVA), using competing risk for DSM and Cox regression for all other endpoints. Results: Median follow-up among survivors was 21 months (range, 3 - 63). Median time from pre-treatment PET to SBRT was 1.8 months (range, 0.1 - 8.1) and median SUVmax was 4.6 (range, 0.6 - 28.4). Twentyseven local, 29 nodal and 41 distant failures were observed. There were 39 disease-related deaths and 64 deaths from other causes. On UVA, SUVmax was significantly associated with all examined endpoints. Tumors with SUVmax > 4.6 had significantly increased 2-year rates of LF (21.1% vs 8.5%, p Z 0.03), NF (25.5% vs 8.2%, p Z 0.001), DF (29.7% vs 11.3%, p Z 0.001) and DSM (19.3% vs 4.1%, p Z 0.002), as well as decreased 2-year OS (59.0% vs 81.2%, p < 0.001). On MVA, SUVmax (HR 1.78, p Z 0.007), KPS (HR 0.97, p < 0.001), age (HR 1.03, p Z 0.046) and male gender (HR 1.65, p Z 0.017) were significantly associated with worse OS. SUVmax was the only variable associated with DSM (HR 2.80, p Z 0.003) and DF (HR 2.79, p Z 0.002). NF was associated with SUVmax (HR 3.12, p Z 0.007) and male gender (HR 2.55, p Z 0.017). SUVmax was not associated with LF, while T
28 Tumoricidal Robotic Radiation: 96% 2-Year Disease-Specific Survival Following Robotic Radiosurgery Stereotactic Body Radiation Therapy for Early Stage Non-Small Cell Lung Cancer H. Bahig,1 E. Filion,1 T. Vu,1 D. Roberge,1 L. Lambert,1 M. Bouchard,2 C. Lavoie,3 R. Doucet,1 D. Be´liveau-Nadeau,1 and M. Campeau1; 1Centre Hospitalier de l’Universite´ de Montre´al, Notre-Dame Hospital, Montreal, QC, Canada, 2Centre Hospitalier Universitaire de Sherbrooke, Montreal, QC, Canada, 3Centre Hospitalier Universitaire de Quebec, Montreal, QC, Canada Purpose/Objective(s): The robotic radiosurgery system allows for precise stereotactic body radiation therapy (SBRT) delivery using near real time in-treatment tracking. In this study, we report our local control, survival and toxicity results for early stage non-small cell lung cancer (NSCLC) treated with robotic radiosurgery SBRT. Materials/Methods: A retrospective analysis of the first 130 out of 200 patients with T1-2N0 NSCLC treated between July 2009 and December 2011 was conducted. Median age was 75 (range, 55-95). Eighty-two percent of patients were medically inoperable and 18% had declined surgery. Median Charlson comorbidity index was 4 (range, 2-14). Work-up included diagnostic CT-scan and TEP scan for all patients; 83% had histological diagnosis. Median tumor size was 2.5 cm (range, 1.1 -4.7 cm), with 82% T1N0 and 18% T2N0. Thirty-three (25%) tumors were central. SBRT was delivered using direct soft tissue tracking in 46 (35%) patients, fiducials in 60 (46%) patients and tracking of adjacent bone in 26 (20%) patients. Median delivered dose was 60 Gy in 3 fractions (uncorrected for tissue inhomogeneity, median biological equivalent dose of 180 Gy, a/b Z 10). Kaplan Meier and Cox proportional hazard ratio models were used for local control and survival analysis. Tumor response were defined as per RECIST criteria v1.1 and based on CT-scans. Toxicities were graded as per CTCAE v3.0. Results: Median follow-up was 20 months. The actuarial 2 years local control (LC), overall survival and disease-specific survival were respectively 93%, 87% and 96%. Local relapse was observed in 7 (5%) patients, regional relapse in 3 (2%) patients and distant relapse in 16 (12%) patients. Every 1 cm increase in tumor diameter was associated with a relative risk (RR) for regional or distant relapse of 2 (95% CI Z 1.2-3.6, p Z 0.009). The adjusted RR for death in patients receiving doses below 60 Gy in 5 fractions (biological equivalent dose < 132 Gy, a/b Z 10) was 3 (95% CI Z 1.25 - 10.4, p Z 0.02). Complete response, partial response and stable disease were observed in 33 (25%), 48 (37%) and 23 (18%) patients, respectively. Two patients with idiopathic pulmonary fibrosis developed grade 5 pneumonitis. Monte Carlo lung V5, V20 and mean dose were 33%, 16%, 8.1 Gy for the first patient and 48%, 21% and 10.6 Gy for the second patient. Toxicities otherwise included 2 patients with grade 3 pneumonitis, 8 patients (6%) with grade 2 costal tenderness and 5 patients (4%) with rib fractures. Conclusions: Excellent LC was obtained with robotic radiosurgery lung SBRT. In general, toxicities were minimal but patients with pulmonary fibrosis could be at risk of severe complications. Smaller tumors and BED > 132 Gy were associated with better outcomes. Author Disclosure: H. Bahig: None. E. Filion: None. T. Vu: None. D. Roberge: None. L. Lambert: None. M. Bouchard: None. C. Lavoie: None. R. Doucet: None. D. Be´liveau-Nadeau: None. M. Campeau: None.