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Prognoses of Patients Who Received Palliative-Intent Radiation Therapy in Recent Years
S698
International Journal of Radiation Oncology Biology Physics
Purpose/Objective(s): Radiation therapy (RT) is frequently employed to palliate spine metastases. There are multiple randomized trials of single fraction (SF) versus multiple fraction (MF) palliative RT with equivalent pain outcomes in uncomplicated bone (including spine) metastases. However, there are little data to inform incidence and predictors of adverse outcomes after RT for uncomplicated spine metastases, including the possible role of spine instability and RT fractionation. Materials/Methods: In total 337 spine metastases in 258 patients treated with RT at a single institution from 2008 to 2013 were retrospectively reviewed. Previously irradiated sites, complicated spine lesions due to spinal cord compression (SCC) or requiring surgery were excluded. The primary outcome was the time to first adverse event (AE) at the treated site, including: symptomatic vertebral body (VB) collapse, hospitalization for site-related pain, salvage spine surgery, vertebroplasty or other interventional procedure for pain, and SCC. A competing risks survival model was used to simultaneously assess potential predictors, including demographic, disease [e.g., Spinal Instability Neoplastic Score, SINS (0-18)], and treatment (e.g., dose fractionation) factors. Death was the competing risk. Clustering was adjusted for with a random-effects model. Results: Median survival was 160 days; 260 days for those receiving post-RT systemic therapies, 40 days for those who did not; 30Gy/10 was given to 49% of sites, 20Gy/5 to 22%, and 8Gy SF to 9%. Median SINS was 7 (IQR 5 to 9). AEs developed in 46 sites (14%), including 12 symptomatic VB collapses, 32 hospitalizations, 4 salvage spinal surgeries, 14 interventional procedures, and 16 SCCs. Median time to first AE - was 121 days (IQR 50-256 days), 75 days for SF RT and 139 days for MF RT. In competing risks MVA, SINS 11 [hazard ratio (HR) Z 2.5 (95% CI 1.3-4.8) p Z 0.006], SF RT [HR Z 6.1 (2.5-15.4), p<0.001] and post-RT systemic therapies [HR Z 3.4 (1.3-8.8), p Z 0.01] were the only significant predictors of AEs. To confirm the SF findings, all SF RT cases (73 sites in 67 patients) in 2008-2013 were reviewed. One-to-one propensity-score matched case-control analysis (matched for demographics, performance status, histology, SINS, and post-RT systemic therapies) confirmed the high HR for AEs with SF [HR Z 3.96 (1.1-14.8) p Z 0.04] versus MF RT. At 90 days post-RT, AEs developed in 23% of SF RT cases versus 6% for MF RT. Conclusions: Single fraction RT and spinal instability were associated with greater risk of clinically significant adverse events in uncomplicated spine metastases. This suggests that for patients with expected survivals >2-3 months, 8Gy x 1 SF RT for uncomplicated spine metastases should be avoided; further studies are required. Author Disclosure: T. Lam: None. H. Uno: None. M.S. Krishnan: None. M. Cheney: None. T.A. Balboni: None.
institution, using standardized dose constraints for 5- fraction regimens as published in AAPM Task Group (TG) 101. We defined the planning target volume (PTV) as all bony structures contained within the 50% isodose line based on original conventional plans. For IMRT plans, optimization was performed to achieve 95% PTV coverage with the prescription dose while meeting published dose constraints for 5-fraction regimens including spinal cord maximum 30 Gy, cauda equina maximum 32 Gy, and bowel maximum 35 Gy. IMRT plans were optimized for a prescription of 30 Gy in 5 fractions, and dosimetric characteristics were extracted for 5-fraction regimens starting at 20 Gy and escalating by 1 Gy per fraction to 35 Gy. Results: IMRT allowed dose escalation to 30 Gy in 5 fractions using AAPM TG 101 constraints, with a mean maximum spinal cord dose of 29.6 Gy, mean maximum cauda equina dose of 31.5 Gy, and mean maximum bowel dose of 29.7 Gy for a 30 Gy prescription and 34.7 Gy for 35 Gy. For the same targets, CRT 5-fraction plans only allowed a dose of 25 Gy: the mean maximum spinal cord dose for a 25 Gy prescription was 29.3 Gy (within constraint) but 35.2 Gy for 30 Gy (above constraint); the mean maximum cauda equina dose for a 25 Gy prescription was 30.4 Gy (within constraint) but 36.4 Gy for 30 Gy (above constraint); the mean maximum bowel dose was 28 Gy for a 25 Gy prescription and 33.6 Gy for 30 Gy (both within constraints). The bowel V20 was extremely low for 5-fraction regimens using IMRT, with a mean V20 of 2% for IMRT plans, and much higher, 39.5%, for CRT plans. Conclusions: IMRT resulted in the ability to dose escalate to bony targets in the lumbosacral region while meeting standardized dose constraints to spinal cord/cauda equina and bowel. IMRT allowed a dose of 30 Gy using a 5-fraction regimen, while CRT allowed a dose of only 25 Gy. Prospective study is warranted to determine if the achieved dose escalation using IMRT results in clinically meaningful improvements in pain control and acceptable toxicity. Author Disclosure: B.H. Ly: None. A. William: None. A. Pollack: None. E. Bossart: None. J. Wright: None.
3240 Dose Escalation Using Conventional Versus IMRT Planning for Hypofractionated Radiation of Lumbosacral Metastases B.H. Ly,1 A. William,1 A. Pollack,1 E. Bossart,1 and J. Wright2; 1 University of Miami, Miami, FL, 2Johns Hopkins University, Baltimore, MD Purpose/Objective(s): The standard approach for palliation of bone metastasis (BM) is conventionally planned radiation (CRT). Randomized studies have shown the equivalence of hypofractionated vs conventionally fractionated regimens, yet reported pain control is poor with either approach. We performed a dosimetric comparison of CRT vs intensitymodulated radiation therapy (IMRT) using standardized dose constraints to investigate if IMRT allowed hypofractionated dose escalation to bony targets in the lumbosacral region, based on the hypothesis that dose escalation will result in superior pain control if it can be delivered within acceptable dose limits to normal tissues. Materials/Methods: We retrospectively re-planned 10 patients with IMRT who were initially treated with palliative CRT for lumbosacral BM at our
3241 Prognoses of Patients Who Received Palliative-Intent Radiation Therapy in Recent Years Y. Hamamoto,1 H. Inata,1 and T. Mochizuki2; 1Saiseikai Imabari Hospital, Imabari-city, Japan, 2Ehime University, Toon-City, Japan Purpose/Objective(s): Nowadays, patients who received palliative intent radiation therapy (PIRT) seemed to live longer compared to two decades ago. To consider the optimal total doses and dose-fractionation schedules of PIRT in recent years, reinvestigation of survival time after PIRT is necessary. Materials/Methods: Between Dec. 2009 and Sept. 2013, 141 patients received PIRT in our institution. Of these 141 patients, 107 patients were able to be followed up until death (n Z 76) or for more than two months (n Z 31). Clinical records concerning the initial PIRT of these 107 patients were examined. Follow-up time ranged from 0.4 to 36.6 months (median 4.2 months). Doses of PIRT ranged from 15 Gy to 60 Gy (mean 33.2 Gy). Sixty-one percent of these patients had received anti-cancer drug therapy before initial PIRT. Twenty-eight patients (26%) received PIRT twice or more during their course. Results: The overall survival rates at 2-years from the initial PIRT were 17% for all 107 patients, 14% for lung cancer, 36% for breast cancer, 18% for digestive tract cancer, 0% for liver/biliary tract/pancreas cancer. On univariate analysis, statistically significant factors for survival were sex (p Z 0.0023), performance status (PS0-1 vs PS2-4) (p Z 0.0152), primary sites (breast vs other cancer) (p Z 0.0049), and PIRT sites (bone/soft tissue vs other sites) (p Z 0.0139). Age (<75 vs 75<), targets of PIRT (primary vs metastatic/disseminated), and administration of anti-cancer drug therapy before PIRT were not statistically significant factors. On multivariate analysis, statistically significant favorable factors for survival were the PIRT site of bone/soft
Volume 90 Number 1S Supplement 2014 tissue (p Z 0.0436) and good performance status (PS0-1) (p Z 0.0046). The overall survival rates at 2-years from the PIRT were 20% for patients received bone/soft tissue PIRT (7% for other sites) and 19% for patients with PS0-1 (13% for PS2-4). Conclusions: Nowadays, small but unignorable number of patients survive for two years or more after PIRT. To maintain quality of life for long term survivors, careful prediction of patient prognoses is necessary before planning of PIRT. Based on our series, the group received PIRT to bone/ soft tissue and the group with good performance status seemed to include long term survivors. Author Disclosure: Y. Hamamoto: None. H. Inata: None. T. Mochizuki: None.
3242 A Multi-institution Pooled Analysis of Oligometastatic Patients Treated With SBRT J. Lee,1 M.T. Milano,2 J. Kao,3 S. Chmura,4 and J.K. Salama1; 1Duke University Medical Center, Durham, NC, 2University of Rochester, Rochester, NY, 3Good Samaritan Hospital Medical Center, West Islip, NY, 4 University of Chicago Hospitals, Chicago, IL Purpose/Objective(s): To report outcomes of oligometastatic (OM) patients treated with SBRT. To identify factors associated with improved treated metastasis control (TMC) and survival. Materials/Methods: OM patients treated with SBRT were either enrolled on institutional protocols, or if ineligible, prospectively followed. Some were treated on a three fraction dose escalation study; most were treated with ten fraction radiation therapy in 5 Gy fractions. Some received escalating doses of concurrent sunitinib per protocol. All were treated to all known metastases. On completion of radiation therapy, patients were followed per institutional protocol, with imaging approximately every 3 months. Univariate analyses were performed on demographic (age, gender), disease based (primary tumor location, treated metastases location, histology, number of metastases treated), and technical (dose fractionation) criteria. Time to progression of primary tumor, distant (not irradiated) disease, and treated metastases were defined as interval from end of radiation to clinical or radiographic evidence of progression. Effects of these on TMC, distant (not irradiated) control (DC), and overall survival (OS) were analyzed using the Kaplan-Meier method. Results: Two hundred fifty-one patients were identified. Median follow-up was 23 months. At last follow-up 47 patients (25%) were alive without evidence of disease. The most common histologies were NSCLC (n Z 60), breast (n Z 50), and colorectal (n Z 46). The predominant fractionation schedule used was 50 Gy in 10 fractions. 7 patients had a synchronous primary. For the entire cohort, TMC was 66%. Median DC was 11 months. Median OS was 23 months. One treated metastasis vs multiple treated metastases was associated with 2 yr OS of 68% vs 52% (p<0.05). Patients with breast cancer primaries had 2 yr OS of 81% vs 52% for other histologies (p<0.01). 2 yr OS for NSCLC patients was 40% vs 64% for other primaries (p<0.01). 2 yr OS for patients with adenocarcinoma was 64% vs 50% for other histologies (p<0.04). 2 yr OS for patients with treated bone metastases was 74% vs 55% for other treated metastases (p<0.02). Breast cancer 2 yr TMC was 78% vs 61% other primaries (p<0.01). 2 year TMC for bone metastases was improved vs other sites of metastases (88% vs 61%, p<0.04). There was a trend for improved 2 yr TMC in patients with one metastasis vs multiple (71% vs 62%, p Z 0.10). Conclusions: In this pooled analysis of OM patients treated with SBRT, patients with a single metastasis, breast cancer primary, adenocarcinoma, and osseous disease were associated with improved outcomes. These data are useful to enhance patient selection in planned prospective studies. Author Disclosure: J. Lee: None. M.T. Milano: None. J. Kao: None. S. Chmura: None. J.K. Salama: None.
Poster Viewing Abstracts S699
3243 Patterns of End of Life Care in Patients With Metastatic Melanoma Requiring Whole-Brain Radiation K. Arneson, A. Dozois, P. Pendyala, and M. Stavas; Vanderbilt University Medical Center, Nashville, TN Purpose/Objective(s): Brain metastases from melanoma are a frequent cause of morbidity and mortality and portend poor prognosis. Patients with multiple brain metastases are poor candidates for aggressive local control of disease and are often treated with whole brain radiation therapy (WBRT) to improve and/or stabilize neurologic symptoms. Median survival for this population following WBRT is typically less than 3 months and thus these patients would benefit from early integration of palliative care services. Here we investigate the patterns of end of life care following WBRT for metastatic melanoma and evaluate the overall efficacy of WBRT in palliating symptoms. Materials/Methods: All patients with histologically proven melanoma with MRI evidence of brain metastases referred to our institution between 2005 and 2012 were retrospectively reviewed for both outcome and treatment response. A total of 43 patients received WBRT as their initial radiation intervention. Patient demographics, the number of lesions, radiographic response, and palliation of symptoms were evaluated as well as the timing of involvement of palliative care. Overall survival (OS) and survival after palliative care referral was assessed using the Kaplan-Meier method. Univariate Cox Regression was used to assess prognostic factors such as number of lesions, neurological symptoms and status of extracranial disease. Results: The median OS following WBRT was 3.6 months. The mean number of brain lesions was 12 and patients who had more than 3 CNS lesions had a significantly lower OS (HR 2.45) after WBRT. There was no difference in the number of patients with neurologic symptoms before WBRT vs after WBRT. Most patients (67%) had progressive disease on post-treatment MRI. The median time to hospice referral was 17 days before death. It was equally as likely for a palliative care referral be made by an in-patient physician during an acute hospitalization as the patient’s out-patient oncology team. Conclusions: Patients with brain metastases from melanoma who receive WBRT have poor outcomes, particularly those with >3 CNS lesions. WBRT did not appear to reduce the burden of neurologic symptoms in our cohort. Though these patients are widely regarded to have a poor prognosis, the median time to hospice referral was only 17 days before death and often an acute hospitalization was the trigger for referral. This short duration is considered insufficient for patients and their families to obtain the full range of benefits of hospice. This data indicates that patients receiving WBRT for metastatic melanoma represent a vulnerable population who would benefit from earlier integration of palliative care services. Radiation oncologists are in a unique position to help educate patients and their families and other care providers about treatment options and prognosis and can be valuable members of the multidisciplinary palliative care team. Author Disclosure: K. Arneson: None. A. Dozois: None. P. Pendyala: None. M. Stavas: None.
3244 Dose Fractionation Schedule Correlates With Survival in WholeBrain Reirradiation: An International Pooled Analysis N. Logie,1 R.B. Jimenez,2 N. Pulenzas,3 C. Denise,4 E. Wong,3 S. Ghosh,1 C. Son,5 H.A. Shih,2 W.W. Wong,4 E.L. Chow,3 and A.M. Fairchild1; 1 Cross Cancer Institute, Edmonton, AB, Canada, 2Massachusetts General Hospital, Boston, MA, 3Odette Cancer Centre, Toronto, ON, Canada, 4 Mayo Clinic Arizona, Scottsdale, AZ, 5University of Chicago, Chicago, IL Purpose/Objective(s): For patients with multiple brain metastases (BM), whole brain radiation therapy (WBRT) alone may be considered. Patients with intracranial progression after a first course of WBRT have limited treatment options. Early data suggests improvement in overall survival
International Journal of Radiation Oncology Biology Physics
Purpose/Objective(s): Radiation therapy (RT) is frequently employed to palliate spine metastases. There are multiple randomized trials of single fraction (SF) versus multiple fraction (MF) palliative RT with equivalent pain outcomes in uncomplicated bone (including spine) metastases. However, there are little data to inform incidence and predictors of adverse outcomes after RT for uncomplicated spine metastases, including the possible role of spine instability and RT fractionation. Materials/Methods: In total 337 spine metastases in 258 patients treated with RT at a single institution from 2008 to 2013 were retrospectively reviewed. Previously irradiated sites, complicated spine lesions due to spinal cord compression (SCC) or requiring surgery were excluded. The primary outcome was the time to first adverse event (AE) at the treated site, including: symptomatic vertebral body (VB) collapse, hospitalization for site-related pain, salvage spine surgery, vertebroplasty or other interventional procedure for pain, and SCC. A competing risks survival model was used to simultaneously assess potential predictors, including demographic, disease [e.g., Spinal Instability Neoplastic Score, SINS (0-18)], and treatment (e.g., dose fractionation) factors. Death was the competing risk. Clustering was adjusted for with a random-effects model. Results: Median survival was 160 days; 260 days for those receiving post-RT systemic therapies, 40 days for those who did not; 30Gy/10 was given to 49% of sites, 20Gy/5 to 22%, and 8Gy SF to 9%. Median SINS was 7 (IQR 5 to 9). AEs developed in 46 sites (14%), including 12 symptomatic VB collapses, 32 hospitalizations, 4 salvage spinal surgeries, 14 interventional procedures, and 16 SCCs. Median time to first AE - was 121 days (IQR 50-256 days), 75 days for SF RT and 139 days for MF RT. In competing risks MVA, SINS 11 [hazard ratio (HR) Z 2.5 (95% CI 1.3-4.8) p Z 0.006], SF RT [HR Z 6.1 (2.5-15.4), p<0.001] and post-RT systemic therapies [HR Z 3.4 (1.3-8.8), p Z 0.01] were the only significant predictors of AEs. To confirm the SF findings, all SF RT cases (73 sites in 67 patients) in 2008-2013 were reviewed. One-to-one propensity-score matched case-control analysis (matched for demographics, performance status, histology, SINS, and post-RT systemic therapies) confirmed the high HR for AEs with SF [HR Z 3.96 (1.1-14.8) p Z 0.04] versus MF RT. At 90 days post-RT, AEs developed in 23% of SF RT cases versus 6% for MF RT. Conclusions: Single fraction RT and spinal instability were associated with greater risk of clinically significant adverse events in uncomplicated spine metastases. This suggests that for patients with expected survivals >2-3 months, 8Gy x 1 SF RT for uncomplicated spine metastases should be avoided; further studies are required. Author Disclosure: T. Lam: None. H. Uno: None. M.S. Krishnan: None. M. Cheney: None. T.A. Balboni: None.
institution, using standardized dose constraints for 5- fraction regimens as published in AAPM Task Group (TG) 101. We defined the planning target volume (PTV) as all bony structures contained within the 50% isodose line based on original conventional plans. For IMRT plans, optimization was performed to achieve 95% PTV coverage with the prescription dose while meeting published dose constraints for 5-fraction regimens including spinal cord maximum 30 Gy, cauda equina maximum 32 Gy, and bowel maximum 35 Gy. IMRT plans were optimized for a prescription of 30 Gy in 5 fractions, and dosimetric characteristics were extracted for 5-fraction regimens starting at 20 Gy and escalating by 1 Gy per fraction to 35 Gy. Results: IMRT allowed dose escalation to 30 Gy in 5 fractions using AAPM TG 101 constraints, with a mean maximum spinal cord dose of 29.6 Gy, mean maximum cauda equina dose of 31.5 Gy, and mean maximum bowel dose of 29.7 Gy for a 30 Gy prescription and 34.7 Gy for 35 Gy. For the same targets, CRT 5-fraction plans only allowed a dose of 25 Gy: the mean maximum spinal cord dose for a 25 Gy prescription was 29.3 Gy (within constraint) but 35.2 Gy for 30 Gy (above constraint); the mean maximum cauda equina dose for a 25 Gy prescription was 30.4 Gy (within constraint) but 36.4 Gy for 30 Gy (above constraint); the mean maximum bowel dose was 28 Gy for a 25 Gy prescription and 33.6 Gy for 30 Gy (both within constraints). The bowel V20 was extremely low for 5-fraction regimens using IMRT, with a mean V20 of 2% for IMRT plans, and much higher, 39.5%, for CRT plans. Conclusions: IMRT resulted in the ability to dose escalate to bony targets in the lumbosacral region while meeting standardized dose constraints to spinal cord/cauda equina and bowel. IMRT allowed a dose of 30 Gy using a 5-fraction regimen, while CRT allowed a dose of only 25 Gy. Prospective study is warranted to determine if the achieved dose escalation using IMRT results in clinically meaningful improvements in pain control and acceptable toxicity. Author Disclosure: B.H. Ly: None. A. William: None. A. Pollack: None. E. Bossart: None. J. Wright: None.
3240 Dose Escalation Using Conventional Versus IMRT Planning for Hypofractionated Radiation of Lumbosacral Metastases B.H. Ly,1 A. William,1 A. Pollack,1 E. Bossart,1 and J. Wright2; 1 University of Miami, Miami, FL, 2Johns Hopkins University, Baltimore, MD Purpose/Objective(s): The standard approach for palliation of bone metastasis (BM) is conventionally planned radiation (CRT). Randomized studies have shown the equivalence of hypofractionated vs conventionally fractionated regimens, yet reported pain control is poor with either approach. We performed a dosimetric comparison of CRT vs intensitymodulated radiation therapy (IMRT) using standardized dose constraints to investigate if IMRT allowed hypofractionated dose escalation to bony targets in the lumbosacral region, based on the hypothesis that dose escalation will result in superior pain control if it can be delivered within acceptable dose limits to normal tissues. Materials/Methods: We retrospectively re-planned 10 patients with IMRT who were initially treated with palliative CRT for lumbosacral BM at our
3241 Prognoses of Patients Who Received Palliative-Intent Radiation Therapy in Recent Years Y. Hamamoto,1 H. Inata,1 and T. Mochizuki2; 1Saiseikai Imabari Hospital, Imabari-city, Japan, 2Ehime University, Toon-City, Japan Purpose/Objective(s): Nowadays, patients who received palliative intent radiation therapy (PIRT) seemed to live longer compared to two decades ago. To consider the optimal total doses and dose-fractionation schedules of PIRT in recent years, reinvestigation of survival time after PIRT is necessary. Materials/Methods: Between Dec. 2009 and Sept. 2013, 141 patients received PIRT in our institution. Of these 141 patients, 107 patients were able to be followed up until death (n Z 76) or for more than two months (n Z 31). Clinical records concerning the initial PIRT of these 107 patients were examined. Follow-up time ranged from 0.4 to 36.6 months (median 4.2 months). Doses of PIRT ranged from 15 Gy to 60 Gy (mean 33.2 Gy). Sixty-one percent of these patients had received anti-cancer drug therapy before initial PIRT. Twenty-eight patients (26%) received PIRT twice or more during their course. Results: The overall survival rates at 2-years from the initial PIRT were 17% for all 107 patients, 14% for lung cancer, 36% for breast cancer, 18% for digestive tract cancer, 0% for liver/biliary tract/pancreas cancer. On univariate analysis, statistically significant factors for survival were sex (p Z 0.0023), performance status (PS0-1 vs PS2-4) (p Z 0.0152), primary sites (breast vs other cancer) (p Z 0.0049), and PIRT sites (bone/soft tissue vs other sites) (p Z 0.0139). Age (<75 vs 75<), targets of PIRT (primary vs metastatic/disseminated), and administration of anti-cancer drug therapy before PIRT were not statistically significant factors. On multivariate analysis, statistically significant favorable factors for survival were the PIRT site of bone/soft
Volume 90 Number 1S Supplement 2014 tissue (p Z 0.0436) and good performance status (PS0-1) (p Z 0.0046). The overall survival rates at 2-years from the PIRT were 20% for patients received bone/soft tissue PIRT (7% for other sites) and 19% for patients with PS0-1 (13% for PS2-4). Conclusions: Nowadays, small but unignorable number of patients survive for two years or more after PIRT. To maintain quality of life for long term survivors, careful prediction of patient prognoses is necessary before planning of PIRT. Based on our series, the group received PIRT to bone/ soft tissue and the group with good performance status seemed to include long term survivors. Author Disclosure: Y. Hamamoto: None. H. Inata: None. T. Mochizuki: None.
3242 A Multi-institution Pooled Analysis of Oligometastatic Patients Treated With SBRT J. Lee,1 M.T. Milano,2 J. Kao,3 S. Chmura,4 and J.K. Salama1; 1Duke University Medical Center, Durham, NC, 2University of Rochester, Rochester, NY, 3Good Samaritan Hospital Medical Center, West Islip, NY, 4 University of Chicago Hospitals, Chicago, IL Purpose/Objective(s): To report outcomes of oligometastatic (OM) patients treated with SBRT. To identify factors associated with improved treated metastasis control (TMC) and survival. Materials/Methods: OM patients treated with SBRT were either enrolled on institutional protocols, or if ineligible, prospectively followed. Some were treated on a three fraction dose escalation study; most were treated with ten fraction radiation therapy in 5 Gy fractions. Some received escalating doses of concurrent sunitinib per protocol. All were treated to all known metastases. On completion of radiation therapy, patients were followed per institutional protocol, with imaging approximately every 3 months. Univariate analyses were performed on demographic (age, gender), disease based (primary tumor location, treated metastases location, histology, number of metastases treated), and technical (dose fractionation) criteria. Time to progression of primary tumor, distant (not irradiated) disease, and treated metastases were defined as interval from end of radiation to clinical or radiographic evidence of progression. Effects of these on TMC, distant (not irradiated) control (DC), and overall survival (OS) were analyzed using the Kaplan-Meier method. Results: Two hundred fifty-one patients were identified. Median follow-up was 23 months. At last follow-up 47 patients (25%) were alive without evidence of disease. The most common histologies were NSCLC (n Z 60), breast (n Z 50), and colorectal (n Z 46). The predominant fractionation schedule used was 50 Gy in 10 fractions. 7 patients had a synchronous primary. For the entire cohort, TMC was 66%. Median DC was 11 months. Median OS was 23 months. One treated metastasis vs multiple treated metastases was associated with 2 yr OS of 68% vs 52% (p<0.05). Patients with breast cancer primaries had 2 yr OS of 81% vs 52% for other histologies (p<0.01). 2 yr OS for NSCLC patients was 40% vs 64% for other primaries (p<0.01). 2 yr OS for patients with adenocarcinoma was 64% vs 50% for other histologies (p<0.04). 2 yr OS for patients with treated bone metastases was 74% vs 55% for other treated metastases (p<0.02). Breast cancer 2 yr TMC was 78% vs 61% other primaries (p<0.01). 2 year TMC for bone metastases was improved vs other sites of metastases (88% vs 61%, p<0.04). There was a trend for improved 2 yr TMC in patients with one metastasis vs multiple (71% vs 62%, p Z 0.10). Conclusions: In this pooled analysis of OM patients treated with SBRT, patients with a single metastasis, breast cancer primary, adenocarcinoma, and osseous disease were associated with improved outcomes. These data are useful to enhance patient selection in planned prospective studies. Author Disclosure: J. Lee: None. M.T. Milano: None. J. Kao: None. S. Chmura: None. J.K. Salama: None.
Poster Viewing Abstracts S699
3243 Patterns of End of Life Care in Patients With Metastatic Melanoma Requiring Whole-Brain Radiation K. Arneson, A. Dozois, P. Pendyala, and M. Stavas; Vanderbilt University Medical Center, Nashville, TN Purpose/Objective(s): Brain metastases from melanoma are a frequent cause of morbidity and mortality and portend poor prognosis. Patients with multiple brain metastases are poor candidates for aggressive local control of disease and are often treated with whole brain radiation therapy (WBRT) to improve and/or stabilize neurologic symptoms. Median survival for this population following WBRT is typically less than 3 months and thus these patients would benefit from early integration of palliative care services. Here we investigate the patterns of end of life care following WBRT for metastatic melanoma and evaluate the overall efficacy of WBRT in palliating symptoms. Materials/Methods: All patients with histologically proven melanoma with MRI evidence of brain metastases referred to our institution between 2005 and 2012 were retrospectively reviewed for both outcome and treatment response. A total of 43 patients received WBRT as their initial radiation intervention. Patient demographics, the number of lesions, radiographic response, and palliation of symptoms were evaluated as well as the timing of involvement of palliative care. Overall survival (OS) and survival after palliative care referral was assessed using the Kaplan-Meier method. Univariate Cox Regression was used to assess prognostic factors such as number of lesions, neurological symptoms and status of extracranial disease. Results: The median OS following WBRT was 3.6 months. The mean number of brain lesions was 12 and patients who had more than 3 CNS lesions had a significantly lower OS (HR 2.45) after WBRT. There was no difference in the number of patients with neurologic symptoms before WBRT vs after WBRT. Most patients (67%) had progressive disease on post-treatment MRI. The median time to hospice referral was 17 days before death. It was equally as likely for a palliative care referral be made by an in-patient physician during an acute hospitalization as the patient’s out-patient oncology team. Conclusions: Patients with brain metastases from melanoma who receive WBRT have poor outcomes, particularly those with >3 CNS lesions. WBRT did not appear to reduce the burden of neurologic symptoms in our cohort. Though these patients are widely regarded to have a poor prognosis, the median time to hospice referral was only 17 days before death and often an acute hospitalization was the trigger for referral. This short duration is considered insufficient for patients and their families to obtain the full range of benefits of hospice. This data indicates that patients receiving WBRT for metastatic melanoma represent a vulnerable population who would benefit from earlier integration of palliative care services. Radiation oncologists are in a unique position to help educate patients and their families and other care providers about treatment options and prognosis and can be valuable members of the multidisciplinary palliative care team. Author Disclosure: K. Arneson: None. A. Dozois: None. P. Pendyala: None. M. Stavas: None.
3244 Dose Fractionation Schedule Correlates With Survival in WholeBrain Reirradiation: An International Pooled Analysis N. Logie,1 R.B. Jimenez,2 N. Pulenzas,3 C. Denise,4 E. Wong,3 S. Ghosh,1 C. Son,5 H.A. Shih,2 W.W. Wong,4 E.L. Chow,3 and A.M. Fairchild1; 1 Cross Cancer Institute, Edmonton, AB, Canada, 2Massachusetts General Hospital, Boston, MA, 3Odette Cancer Centre, Toronto, ON, Canada, 4 Mayo Clinic Arizona, Scottsdale, AZ, 5University of Chicago, Chicago, IL Purpose/Objective(s): For patients with multiple brain metastases (BM), whole brain radiation therapy (WBRT) alone may be considered. Patients with intracranial progression after a first course of WBRT have limited treatment options. Early data suggests improvement in overall survival