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Response to Palliative Radiotherapy (PRT) in Patients (PTS) with Painful Bone Metastases depending on the site of Metastases and the Primary Tumor
I. J. Radiation Oncology d Biology d Physics
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Volume 81, Number 2, Supplement, 2011
was 92% at 12 months. Lesion volume of .2 cm3 was associated with worse local control (p = 0.0028). Distant brain control was 33.4% at 12 months with the median new lesion-free survival being 7.6 months. Median overall survival (OS) was 11.7 months. Multivariate analysis revealed that age . 60 (p = 0.003), KPS\80 (p = 0.023), and uncontrolled primary disease (p\0.001) were significant adverse prognostic factors for OS. As a continuous variable, tumor volume was associated with worse OS with a HR of 1.11 (p = 0.009). The same analysis failed to show number of metastases and presence of extracranial disease to be prognostic. When applied to our patients, RPA and DS-GPA indices split the data set into prognostically different groups. In the RPA groups, median OS was not reached for class I, was 10.8 months for class II, and 1.8 months for class III (p = 0.0012). In the GPA groups, median OS was 4 months for \0.05 points, 6.3 months for 1 point, 10.5 months for 1.5 points, 17 months for 2 points, and not reached for .2.5 points (p = 0.0011). Neither RPA, nor DS-GPA was prognostic for local tumor control or new lesion-free survival. Conclusions: Application of DS-GPA to a brain metastasis database of patients treated with SRS is valid and provides additional prognostic refinement over that provided by the RPA. GPA may also allow for improved patient selection to undergo either initial SRS alone or SRS in combination with other therapies and should be studied further. Author Disclosure: A. Likhacheva: None. C. Pinnix: None. N. Parikh: None. P. Allen: None. M. McAleer: None. M. Chiu: None. S. Erik: None. A. Mahajan: None. S. Prabhu: None. E. Chang: None.
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Identification of Clinical Factors to Help Predict for Early Rapid MRI Progression (ERMP) of Brain Metastasis Patients Undergoing Gamma Knife Radiosurgery
C. C. Pinnix, A. Likhacheva, N. Parikh, M. S. K. Chiu, P. K. Allen, A. Mahajan, M. McAleer, E. P. Sulman, N. Guha-Thakurta, E. Chang M.D. Anderson Cancer Center, Houston, TX Purpose/Objective(s): Stereotactic radiosurgery (SRS) is an established tool for the primary treatment of metastatic intracranial tumors; however for new brain metastasis (BM), no consensus regarding the respective roles of Gamma Knife (GK) radiosurgery and/or whole brain radiotherapy (WBRT) exists. In our clinical experience we have identified not infrequently, that certain patients develop new intracranial metastases in the period between the MRI diagnosis of metastatic intracranial disease and the GK planning MRI performed the day of GK. In these patients, the same day planning MRI scan revealed unexpected new brain lesions, as compared to the MRI used to determine the patient was a candidate for GK. This study evaluates possible risk factors for the development of new BM during the time interval between the diagnostic and planning MRIs. Materials/Methods: An institutional review board approved, retrospective database of 243 patients with histologically confirmed metastatic cancer who underwent GK radiosurgery from July 2009- January 2010 for the treatment of BM was generated. Patients with new BMs recognized on the planning GK MRI were identified. Potential prognostic factors to predict for the occurrence of early, rapid MRI progression (ERMP) prior to GK radiosurgery were evaluated. Results: 60 patients (24.7%) developed new BMs on the planning GK MRI that were not present on previous diagnostic MR imaging. Prognostic factors for ERMP were Karnofsky performance status (KPS) of less than or equal to 70 (p = 0.013), the number of BMs on the initial diagnostic scan (p = 0.009), Graded Prognostic Assessment (GPA) of 2 or less (0.0 - 2.0 versus 2.5 - 4.0, p = 0.001), control of primary disease (p = 0.004), the status of extracranial disease (stable, progressive or no evidence of disease, p = 0.001) and the time between the diagnostic and GK planning MRIs (p = 0.0031). The Recursive Partitioning Analysis (RPA) Score was not a positive prognostic factor (p = 0.329). Melanoma histology was not a positive prognostic factor, but did approach borderline statistical significance (p = 0.097). Conclusions: The phenomenon of ERMP is not trivial with an incidence of 25%. Several factors including GPA less than or equal to 2, KPS less than or equal to 70 and the initial number of BMs correlate with increased incidence of ERMP. Patients with these adverse prognostic factors are more likely to develop ERMP and may be more appropriately treated with up-front WBRT, with SRS reserved for treatment of any recurrences. Author Disclosure: C.C. Pinnix: None. A. Likhacheva: None. N. Parikh: None. M.S.K. Chiu: None. P.K. Allen: None. A. Mahajan: None. M. McAleer: None. E.P. Sulman: None. N. Guha-Thakurta: None. E. Chang: None.
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Response to Palliative Radiotherapy (PRT) in Patients (PTS) with Painful Bone Metastases depending on the site of Metastases and the Primary Tumor
J. Pardo1, M. Murcia1, A. Biete2,3, A. Alvarado1, N. Feltes1, J. Olivera4, J. Luna4, J. Vara4, I. Prieto4, A. Perez4 1 Capio-Hospital General de Catalunya, Barcelona 08195, Spain, 2Hospital Clinic i Provincial, Barcelona, Spain, 3Universitat de Barcelona, Barcelona, Spain, 4Capio-Fundacion Jimenez Diaz, Madrid, Spain
Purpose/Objective(s): To determine if the response to PRT in pts with painful bone metastases is influenced by the site of metastases and the primary tumor. Materials/Methods: From January 2004 to January 2010, 672 consecutive pts with painful bone metastases were referred to our departments for PRT and enrolled in this study. There were 450 males (66.96%) and 222 females (33.03%), with a median age of 67.86 years (range 35 - 93). The most common primary cancer sites were Lung 28.86% (194 pts), prostate 19.34% (130 pts), and breast 17.26% (116 pts). The most common metastatic locations were spine 51.19% (344 pts), pelvis 30.65% (206 pts) and lower extremities 6.54% (44 pts). All patients were treated with the same regimen 10 x 3 Gy for a total dose of 30 Gy in ten days. Pain intensity effectiveness of pain palliation were evaluated using the visual analog pain score (VAS) score prior to start the treatment, at the end of treatment and 2 weeks after the treatment was completed. Patients were asked to communicate its doctor when the intensity of pain started to diminish. Partial response was defined as reduction equal or higher to 2 points in the VAS score. Total response was defined as achieving a maximum VAS score value of 2. Results: The average VAS score prior to PT was 6.98 point (range 4 - 10). Partial pain relief was achieved in 252 (37.50%) of the patients and complete relief was achieved in 338 (50.29%) of the patients. Eighty-two (12.2%) of the patients showed no response to treatment. Considering responders patients, the average VAS score at the end of PT was 2.83 (range 0 - 8) and the average VAS
Proceedings of the 53rd Annual ASTRO Meeting score at 2 weeks was 2.10 (range 0 - 8). Response started at a medium dose of 22.10 Gy (range 9 - 30) with an average improvement in the VAS score of 4.01 points (range 2 - 8). The median duration of pain control was 13.1 months (range 2 - 48). Thirty-six (2.67%) of the patients developed recurrent pain and had to be retreated. Regarding the primary tumor breast cancer patients started response at lower doses (17.8 Gy vs 20.4 Gy lung vs 21 Gy prostate), had higher complete response rates (81.63% vs 67% prostate vs 30.76% lung), lower partial response rates (8.16% vs 34.06% lung vs 21.73% prostate) and lower reirradiation rates (2.04% vs 4.39% lung). Regarding the site of the metastases, the only difference was found in the average duration of treatment response (8.29 months vs 4.73 months in pelvis metastases). Conclusions: Breast cancer bone metastases respond earlier to treatment, achieve more complete response rates and need less reirradiation procedures. Spine metastases have a larger free pain period. Author Disclosure: J. Pardo: None. M. Murcia: None. A. Biete: None. A. Alvarado: None. N. Feltes: None. J. Olivera: None. J. Luna: None. J. Vara: None. I. Prieto: None. A. Perez: None.
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Trends in Symptom Control and Palliative Care Abstracts at ASTRO 2001 to 2010 1
J. A. Jones , S. Lutz2 1
University of Pennsylvania, Philadelphia, PA, 2Blanchard Valley Health System, Findlay, OH
Purpose/Objective(s): Palliative care abstracts historically have made up a minor proportion of submissions to ASTRO annual meetings. However, the past ten years have seen an increasing dedication to palliative radiation oncology topics. In 2004 ASTRO designated ‘‘palliative care’’ as a unique research topic searchable in the annual abstract supplement index. Here we document the trends in research into palliative care and symptom control by reviewing ASTRO abstracts from 2001 to 2010. Materials/Methods: The proportion of abstracts submitted to ASTRO from 2004 to 2010 that were designated ‘‘palliative care’’ by the submitting authors was categorized and reviewed. Each abstract was classified by type of study, endpoints measured, radiotherapy intent, anatomic site treated, symptoms palliated, country of origin, and type of radiotherapy utilized. Additionally, all abstracts accepted for the annual meeting from 2001 to 2010 were reviewed to determine if they had symptom control or palliative endpoints and were characterized with the same variables. Results: The number of unique abstracts categorized as ‘‘palliative care’’ increased from 6 in 2004 to 22 in 2010. Palliative care as a proportion of total abstracts ranged from 0.5% in 2005 to 1.3% in 2008. Only 4% of those abstracts contained results from randomized, controlled trials. The most commonly measured endpoint was pain relief following external beam radiotherapy. Forty percent of these palliative care abstracts were submitted by authors from Canada, while 61% of the abstracts were submitted by authors from countries other than the United States. A more exhaustive review of greater than 11,000 abstracts accepted at ASTRO since 2001 revealed that many more abstracts focused on radiotherapy with palliative intent or on symptom control than the topic index indicated. Up to 4.3% of all abstracts were found to focus on symptom control and palliative care. Areas of increasing representation among palliative care abstracts at ASTRO included the use of stereotactic radiotherapy for palliation, outcomes from rapid access radiotherapy programs, the use of screening tools to help predict burdensome symptoms, increased attention to symptom management during definitive radiotherapy and prognostic tools to refine estimates of life expectancy. Conclusions: There has been growth in research about palliative care and symptom management within the field of radiation oncology over the past ten years, yet significant opportunities for further investigations remain. Palliative radiotherapy will continue to be an important area of investigation to promote compassionate, personalized care for patients with locally advanced and metastatic cancer. Author Disclosure: J.A. Jones: None. S. Lutz: None.
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Repeat Whole Brain Irradiation for Patients with Brain Metastases
S. Guo, C. A. Reddy, S. T. Chao, J. H. Suh Cleveland Clinic, Cleveland, OH Purpose/Objective(s): The use of repeat whole brain radiation therapy (WBRT) in patients with progressive or recurrent brain metastases who have previously undergone WBRT is controversial. We retrospectively reviewed our single institutional experience of repeat whole brain irradiation in an era where stereotactic radiosurgery was also available for treatment of brain metastases. Materials/Methods: Using our institutional review board-approved database of patients with brain metastases, we identified 41 patients who received re-irradiation for progressive or recurrent brain metastases from 1996 to 2010. The median age at re-irradiation was 56 (range 30 - 72). The most common primary sites were lung (66%) and breast (20%). The median dose used for initial WBRT was 30 Gy in 10 fx (range: 20 - 37.5). The median dose used for repeat WBRT was 20 Gy in 10 fx (range: 14 - 30). Median KPS at repeat WBRT was 70 (range: 40 - 90) Median survival times were calculated using Kaplan-Meier analysis. Results: Thirty-eight patients (93%) completed repeat WBRT. Eleven patients had improvement of neurologic symptoms (27%), 10 had stable neurologic symptoms (24%), 13 had worsening symptoms (32%), and 7 were not evaluable (17%). Median survival following repeat WBRT was 3.3 months (range 0.4 - 21.3). Five patients (12%) were alive beyond 6 months and 3 patients (7%) were alive beyond 12 months. Prognostic factors were evaluated for survival including age, KPS, absence of extracranial disease, controlled primary, RPA, interval between WBRT courses, number of lesions, and clinical response after initial WBRT. None were statistically significant predictors for survival. Patients who experienced an improvement of neurologic symptoms showed a trend towards improved survival compared to patients who had stable or worsening symptoms (p = 0.0566). Conclusions: Modest survival times are seen after repeat WBRT. Patients with improved neurologic symptoms after repeat WBRT showed a trend towards improved overall survival. Repeat whole brain irradiation is safe in carefully selected patients and may be a useful treatment modality in these patients. Author Disclosure: S. Guo: None. C.A. Reddy: None. S.T. Chao: None. J.H. Suh: None.
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was 92% at 12 months. Lesion volume of .2 cm3 was associated with worse local control (p = 0.0028). Distant brain control was 33.4% at 12 months with the median new lesion-free survival being 7.6 months. Median overall survival (OS) was 11.7 months. Multivariate analysis revealed that age . 60 (p = 0.003), KPS\80 (p = 0.023), and uncontrolled primary disease (p\0.001) were significant adverse prognostic factors for OS. As a continuous variable, tumor volume was associated with worse OS with a HR of 1.11 (p = 0.009). The same analysis failed to show number of metastases and presence of extracranial disease to be prognostic. When applied to our patients, RPA and DS-GPA indices split the data set into prognostically different groups. In the RPA groups, median OS was not reached for class I, was 10.8 months for class II, and 1.8 months for class III (p = 0.0012). In the GPA groups, median OS was 4 months for \0.05 points, 6.3 months for 1 point, 10.5 months for 1.5 points, 17 months for 2 points, and not reached for .2.5 points (p = 0.0011). Neither RPA, nor DS-GPA was prognostic for local tumor control or new lesion-free survival. Conclusions: Application of DS-GPA to a brain metastasis database of patients treated with SRS is valid and provides additional prognostic refinement over that provided by the RPA. GPA may also allow for improved patient selection to undergo either initial SRS alone or SRS in combination with other therapies and should be studied further. Author Disclosure: A. Likhacheva: None. C. Pinnix: None. N. Parikh: None. P. Allen: None. M. McAleer: None. M. Chiu: None. S. Erik: None. A. Mahajan: None. S. Prabhu: None. E. Chang: None.
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Identification of Clinical Factors to Help Predict for Early Rapid MRI Progression (ERMP) of Brain Metastasis Patients Undergoing Gamma Knife Radiosurgery
C. C. Pinnix, A. Likhacheva, N. Parikh, M. S. K. Chiu, P. K. Allen, A. Mahajan, M. McAleer, E. P. Sulman, N. Guha-Thakurta, E. Chang M.D. Anderson Cancer Center, Houston, TX Purpose/Objective(s): Stereotactic radiosurgery (SRS) is an established tool for the primary treatment of metastatic intracranial tumors; however for new brain metastasis (BM), no consensus regarding the respective roles of Gamma Knife (GK) radiosurgery and/or whole brain radiotherapy (WBRT) exists. In our clinical experience we have identified not infrequently, that certain patients develop new intracranial metastases in the period between the MRI diagnosis of metastatic intracranial disease and the GK planning MRI performed the day of GK. In these patients, the same day planning MRI scan revealed unexpected new brain lesions, as compared to the MRI used to determine the patient was a candidate for GK. This study evaluates possible risk factors for the development of new BM during the time interval between the diagnostic and planning MRIs. Materials/Methods: An institutional review board approved, retrospective database of 243 patients with histologically confirmed metastatic cancer who underwent GK radiosurgery from July 2009- January 2010 for the treatment of BM was generated. Patients with new BMs recognized on the planning GK MRI were identified. Potential prognostic factors to predict for the occurrence of early, rapid MRI progression (ERMP) prior to GK radiosurgery were evaluated. Results: 60 patients (24.7%) developed new BMs on the planning GK MRI that were not present on previous diagnostic MR imaging. Prognostic factors for ERMP were Karnofsky performance status (KPS) of less than or equal to 70 (p = 0.013), the number of BMs on the initial diagnostic scan (p = 0.009), Graded Prognostic Assessment (GPA) of 2 or less (0.0 - 2.0 versus 2.5 - 4.0, p = 0.001), control of primary disease (p = 0.004), the status of extracranial disease (stable, progressive or no evidence of disease, p = 0.001) and the time between the diagnostic and GK planning MRIs (p = 0.0031). The Recursive Partitioning Analysis (RPA) Score was not a positive prognostic factor (p = 0.329). Melanoma histology was not a positive prognostic factor, but did approach borderline statistical significance (p = 0.097). Conclusions: The phenomenon of ERMP is not trivial with an incidence of 25%. Several factors including GPA less than or equal to 2, KPS less than or equal to 70 and the initial number of BMs correlate with increased incidence of ERMP. Patients with these adverse prognostic factors are more likely to develop ERMP and may be more appropriately treated with up-front WBRT, with SRS reserved for treatment of any recurrences. Author Disclosure: C.C. Pinnix: None. A. Likhacheva: None. N. Parikh: None. M.S.K. Chiu: None. P.K. Allen: None. A. Mahajan: None. M. McAleer: None. E.P. Sulman: None. N. Guha-Thakurta: None. E. Chang: None.
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Response to Palliative Radiotherapy (PRT) in Patients (PTS) with Painful Bone Metastases depending on the site of Metastases and the Primary Tumor
J. Pardo1, M. Murcia1, A. Biete2,3, A. Alvarado1, N. Feltes1, J. Olivera4, J. Luna4, J. Vara4, I. Prieto4, A. Perez4 1 Capio-Hospital General de Catalunya, Barcelona 08195, Spain, 2Hospital Clinic i Provincial, Barcelona, Spain, 3Universitat de Barcelona, Barcelona, Spain, 4Capio-Fundacion Jimenez Diaz, Madrid, Spain
Purpose/Objective(s): To determine if the response to PRT in pts with painful bone metastases is influenced by the site of metastases and the primary tumor. Materials/Methods: From January 2004 to January 2010, 672 consecutive pts with painful bone metastases were referred to our departments for PRT and enrolled in this study. There were 450 males (66.96%) and 222 females (33.03%), with a median age of 67.86 years (range 35 - 93). The most common primary cancer sites were Lung 28.86% (194 pts), prostate 19.34% (130 pts), and breast 17.26% (116 pts). The most common metastatic locations were spine 51.19% (344 pts), pelvis 30.65% (206 pts) and lower extremities 6.54% (44 pts). All patients were treated with the same regimen 10 x 3 Gy for a total dose of 30 Gy in ten days. Pain intensity effectiveness of pain palliation were evaluated using the visual analog pain score (VAS) score prior to start the treatment, at the end of treatment and 2 weeks after the treatment was completed. Patients were asked to communicate its doctor when the intensity of pain started to diminish. Partial response was defined as reduction equal or higher to 2 points in the VAS score. Total response was defined as achieving a maximum VAS score value of 2. Results: The average VAS score prior to PT was 6.98 point (range 4 - 10). Partial pain relief was achieved in 252 (37.50%) of the patients and complete relief was achieved in 338 (50.29%) of the patients. Eighty-two (12.2%) of the patients showed no response to treatment. Considering responders patients, the average VAS score at the end of PT was 2.83 (range 0 - 8) and the average VAS
Proceedings of the 53rd Annual ASTRO Meeting score at 2 weeks was 2.10 (range 0 - 8). Response started at a medium dose of 22.10 Gy (range 9 - 30) with an average improvement in the VAS score of 4.01 points (range 2 - 8). The median duration of pain control was 13.1 months (range 2 - 48). Thirty-six (2.67%) of the patients developed recurrent pain and had to be retreated. Regarding the primary tumor breast cancer patients started response at lower doses (17.8 Gy vs 20.4 Gy lung vs 21 Gy prostate), had higher complete response rates (81.63% vs 67% prostate vs 30.76% lung), lower partial response rates (8.16% vs 34.06% lung vs 21.73% prostate) and lower reirradiation rates (2.04% vs 4.39% lung). Regarding the site of the metastases, the only difference was found in the average duration of treatment response (8.29 months vs 4.73 months in pelvis metastases). Conclusions: Breast cancer bone metastases respond earlier to treatment, achieve more complete response rates and need less reirradiation procedures. Spine metastases have a larger free pain period. Author Disclosure: J. Pardo: None. M. Murcia: None. A. Biete: None. A. Alvarado: None. N. Feltes: None. J. Olivera: None. J. Luna: None. J. Vara: None. I. Prieto: None. A. Perez: None.
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Trends in Symptom Control and Palliative Care Abstracts at ASTRO 2001 to 2010 1
J. A. Jones , S. Lutz2 1
University of Pennsylvania, Philadelphia, PA, 2Blanchard Valley Health System, Findlay, OH
Purpose/Objective(s): Palliative care abstracts historically have made up a minor proportion of submissions to ASTRO annual meetings. However, the past ten years have seen an increasing dedication to palliative radiation oncology topics. In 2004 ASTRO designated ‘‘palliative care’’ as a unique research topic searchable in the annual abstract supplement index. Here we document the trends in research into palliative care and symptom control by reviewing ASTRO abstracts from 2001 to 2010. Materials/Methods: The proportion of abstracts submitted to ASTRO from 2004 to 2010 that were designated ‘‘palliative care’’ by the submitting authors was categorized and reviewed. Each abstract was classified by type of study, endpoints measured, radiotherapy intent, anatomic site treated, symptoms palliated, country of origin, and type of radiotherapy utilized. Additionally, all abstracts accepted for the annual meeting from 2001 to 2010 were reviewed to determine if they had symptom control or palliative endpoints and were characterized with the same variables. Results: The number of unique abstracts categorized as ‘‘palliative care’’ increased from 6 in 2004 to 22 in 2010. Palliative care as a proportion of total abstracts ranged from 0.5% in 2005 to 1.3% in 2008. Only 4% of those abstracts contained results from randomized, controlled trials. The most commonly measured endpoint was pain relief following external beam radiotherapy. Forty percent of these palliative care abstracts were submitted by authors from Canada, while 61% of the abstracts were submitted by authors from countries other than the United States. A more exhaustive review of greater than 11,000 abstracts accepted at ASTRO since 2001 revealed that many more abstracts focused on radiotherapy with palliative intent or on symptom control than the topic index indicated. Up to 4.3% of all abstracts were found to focus on symptom control and palliative care. Areas of increasing representation among palliative care abstracts at ASTRO included the use of stereotactic radiotherapy for palliation, outcomes from rapid access radiotherapy programs, the use of screening tools to help predict burdensome symptoms, increased attention to symptom management during definitive radiotherapy and prognostic tools to refine estimates of life expectancy. Conclusions: There has been growth in research about palliative care and symptom management within the field of radiation oncology over the past ten years, yet significant opportunities for further investigations remain. Palliative radiotherapy will continue to be an important area of investigation to promote compassionate, personalized care for patients with locally advanced and metastatic cancer. Author Disclosure: J.A. Jones: None. S. Lutz: None.
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Repeat Whole Brain Irradiation for Patients with Brain Metastases
S. Guo, C. A. Reddy, S. T. Chao, J. H. Suh Cleveland Clinic, Cleveland, OH Purpose/Objective(s): The use of repeat whole brain radiation therapy (WBRT) in patients with progressive or recurrent brain metastases who have previously undergone WBRT is controversial. We retrospectively reviewed our single institutional experience of repeat whole brain irradiation in an era where stereotactic radiosurgery was also available for treatment of brain metastases. Materials/Methods: Using our institutional review board-approved database of patients with brain metastases, we identified 41 patients who received re-irradiation for progressive or recurrent brain metastases from 1996 to 2010. The median age at re-irradiation was 56 (range 30 - 72). The most common primary sites were lung (66%) and breast (20%). The median dose used for initial WBRT was 30 Gy in 10 fx (range: 20 - 37.5). The median dose used for repeat WBRT was 20 Gy in 10 fx (range: 14 - 30). Median KPS at repeat WBRT was 70 (range: 40 - 90) Median survival times were calculated using Kaplan-Meier analysis. Results: Thirty-eight patients (93%) completed repeat WBRT. Eleven patients had improvement of neurologic symptoms (27%), 10 had stable neurologic symptoms (24%), 13 had worsening symptoms (32%), and 7 were not evaluable (17%). Median survival following repeat WBRT was 3.3 months (range 0.4 - 21.3). Five patients (12%) were alive beyond 6 months and 3 patients (7%) were alive beyond 12 months. Prognostic factors were evaluated for survival including age, KPS, absence of extracranial disease, controlled primary, RPA, interval between WBRT courses, number of lesions, and clinical response after initial WBRT. None were statistically significant predictors for survival. Patients who experienced an improvement of neurologic symptoms showed a trend towards improved survival compared to patients who had stable or worsening symptoms (p = 0.0566). Conclusions: Modest survival times are seen after repeat WBRT. Patients with improved neurologic symptoms after repeat WBRT showed a trend towards improved overall survival. Repeat whole brain irradiation is safe in carefully selected patients and may be a useful treatment modality in these patients. Author Disclosure: S. Guo: None. C.A. Reddy: None. S.T. Chao: None. J.H. Suh: None.
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