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Safety and Outcomes of Multiple Courses of Stereotactic Body Radiation Therapy to the Lung
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International Journal of Radiation Oncology Biology Physics
outcomes. Biologically equivalent doses <100Gy10 vs. 100-132Gy10 vs. 132Gy10were associated with 2-year LC of 67% vs. 93% vs. 97% (pZ0.01), DSS of 50% vs. 87% vs. 93% (pZ0.01) and OS of 50% vs. 76% vs. 88% (pZ0.04), respectively. Tumor stage T1a vs. T1b vs. T2 were associated with 2-year LC of 97% vs. 95% vs. 92% (pZ0.05), DSS of 93% vs. 94% vs. 83% (pZ0.001) and OS of 89% vs. 86% vs. 76% (pZ0.03). Conclusion: The algorithm for patient-adapted treatment selection adopted in our center allows for effective and safe lung SABR. Results from our large cohort support previously reported improved outcomes of lung SABR with dose escalation. Author Disclosure: H. Bahig: Invited speaker Accuray symposium; Accuray. E.J. Filion: Invited speaker Accuray symposium 22-09-2013; Accuray. T. Vu: None. L. Lambert: None. D. Mathieu: None. D. Roberge: Invited speaker Accuray symposium 22-09-2013; Accuray. M. Bouchard: None. C. Lavoie: None. D. Beliveau-Nadeau: None. J. Prenovault: None. M. Campeau: None.
Lung treatment, had no history of previous thoracic radiation and a minimum of 12 months follow-up. 12 patients had synchronous MPLC, 14 had metachronous, and 1 had both. Toxicity was prospectively graded per CTCAE v3.0. The Kaplan-Meier method was used to estimate local failure (LF), disease-free survival (DFS), progression- free survival (PFS), and overall survival (OS) (all time-to-event endpoints were defined as the time from treatment initiation to event or the day of last follow-up). For survival outcomes potential associations were assessed in univariate and multivariate analyses using the Cox proportional hazards model. Based on P values 0.10 in univariate analyses, and clinical relevance, multivariate analysis was performed using a stepwise regression model to identify variables that have an effect (2-sided P value 0.05) on survival outcomes. Results: Median follow-up was 36.5 (range, 12.2-87.2) months. Median age of patients at first diagnosis was 76 years (range, 57 - 86). 25 patients received two SBRT courses, 1 had three courses, and 1 had four. Of the 27 patients, 23 had pathological diagnosis of lung cancer. In total, 57 lesions were treated by SBRT in this cohort of patients [median dose/ fraction of 48 Gy/ 4 fractions (range, 60 Gy/ 8 fractions-30 Gy/ 5 fractions)]. 47% of these lesions (nZ27) had biopsy proven lung cancer. Local control rate at 3 years was 86%. Three-year DFS and OS were 63% and 67%, respectively. On univariate analysis patients with metachronous MPLC [HR: 0.25 (95% CI; 0.07-0.92, pZ0.03) and T1 tumors [HR: 0.18 (95% CI; 0.050.66, pZ0.009) had significantly better OS. On multivariate analysis only metachronous MPLC [HR: 0.18 (95% CI; 0.05-0.66, pZ0.01) retained significance on OS. Acute toxicity grade 2 was reported in 5 patients (1 patient with grade 2 fatigue and 4 with grade 2 pneumonitis) and 2 patients had late toxicities grade 2 (G2 chest wall pain, G3 dysphagia). None of the patients developed grade 3 pneumonitis. Conclusion: SBRT appears to be effective and safe for the management of MPLC. Patients should be followed indefinitely following SBRT as further second primary cancers may be managed with SBRT. Author Disclosure: A. Dayyat: None.
3106 Risk Adapted Radiation Therapy for Thymoma: A Single-Institution 30 Year Review N. Lalani,1 N. Safieddine,2 D. Hwang,2 S. Keshavjee,2 A. Bezjak,1 and A.M. Brade1; 1Princess Margaret Cancer Centre, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada Purpose/Objective(s): Resection is the standard of care for localized thymic malignancies. Post-operative radiation therapy (RT) is often employed to prevent local recurrence, but the optimal dose has not yet been established. Personalized therapy using risk-adapted low-dose RT (LD) for select patients may provide equivalent local control and decreased toxicity compared to conventional high-dose regimens (HD). Our institution employs such a risk-adapted strategy and we present here our long term results. Materials/Methods: Radiation and surgical oncology databases from a single tertiary care institution were queried from 1980-2012. Retrospective analyses using electronic patient records were performed to obtain clinical and demographic data. Actuarial analyses and correlation of outcomes with clinical variables were performed. The mean follow-up was 9.4 years (0.5-25.5). Results: One hundred fifty-seven patients treated with post-operative RT from 1980-2012 were identified. Of these, 104 (66%) were treated with LD (36-42 Gy) in a risk-adapted fashion while the remaining 53 (44%) received HD (42-66Gy). The majority of patients were Masaoka-Koga (MK) stage II: 66 (42%) or III: 61 (39%) and WHO grade B1: 30 (19%), B2: 30 (19%) or B3: 30 (19%). Complete surgical resection was obtained in 79 (50%) of patients. A total of 49 (31%) of patients experienced relapse: 22 (14%) regional, 8 (5%) local, and 6 (4%) distant. Patients receiving LD experienced a local relapse rate of 4% compared to 7% in the HD group (pZ0.035). LD and MK stage were predictive of local recurrence (pZ0.035). Conclusion: Risk-adapted post-operative RT may improve the therapeutic ratio for patients with thymoma. Long-term randomized trials are required to further identify patients best suited to this approach. Author Disclosure: N. Lalani: None. N. Safieddine: None. D. Hwang: None. S. Keshavjee: None. A. Bezjak: None. A.M. Brade: None.
3107 Safety and Outcomes of Multiple Courses of Stereotactic Body Radiation Therapy to the Lung C.V. Sole, A.J. Hope, A. Dayyat, A. Sun, J. Cho, O. Wong, L. Lee, A.M. Brade, A. Bezjak, and M.E. Giuliani; Princess Margaret Cancer Centre/University of Toronto, ON, Canada Purpose/Objective(s): Patients with multiple primary lung cancers (MPLC) present a therapeutic challenge. We evaluated the role of stereotactic body radiation therapy (SBRT) in this population in terms of efficacy and safety. Materials/Methods: A prospective lung SBRT registry was retrospectively explored to identify patients who were treated with more than one SBRT
3108 Does Motion Management Technique for Lung SBRT Influence Local Control: A Single-Institutional Experience Comparing Abdominal Compression to Breath Hold Technique G.M. Videtic, N.M. Woody, C.A. Reddy, T. Djemil, and K.L. Stephans; Cleveland Clinic, Cleveland, OH Purpose/Objective(s): Since 2003, we have used abdominal compression (COMP) for lung stereotactic body radiation therapy (SBRT). In 11/2009, breath hold technique by automatic breath control (ABC) device was introduced especially for fit oligometastatic patients (pts). We now compare local failure (LF) results for COMP versus ABC. Materials/Methods: Our IRB-approved SBRT registry was queried for pts. treated for either a primary lung cancer (PRIME) or an oligometastatic (OLIGO) diagnosis with a minimum 6 months follow-up. SBRT was delivered by a stereotactic-specific LINAC platform with vacuum-bag based immobilization, and infrared-based X-ray positioning system+/CBCT for image-guidance. With COMP, tumor excursion was limited to <1cm and the ITV was created one of two way dependent on treatment era: 1. Fused GTV excursion CTs from free breathing, fixed inhale and exhale travel or 2. by 4DCT, with PTV created from the MIP ITV after adding a 5mm margin. With ABC, 3 serial CT image sets confirmed target immobilization, with the PTV generated after 5 mm was added to the static GTV. SBRT was delivered either with dynamic arcs or step-and-shoot intensityemodulated beams. SBRT dose/fractionation schedules reflected treatment era, tumor location, clinician preference, and trial-based experience. LF was defined as progressive and increasing CT scan abnormalities confirmed by progressive and incremental increases in a lesion’s SUVs on serial PET imaging, with or without biopsy. Results: For the interval 10/2003 to 7/2014, 873 pts with 931 lesions were treated. Overall pt. characteristics were: 455 (52.1%) female; 83.9% Caucasian; median age 73 years (range 37-97); median KPS 80 (range 40100); median BMI 26.2 (range 12.1-56.3). Overall tumor characteristics were: median tumor size 2.2 cm (range 0.7-10.0); median PET SUVmax
International Journal of Radiation Oncology Biology Physics
outcomes. Biologically equivalent doses <100Gy10 vs. 100-132Gy10 vs. 132Gy10were associated with 2-year LC of 67% vs. 93% vs. 97% (pZ0.01), DSS of 50% vs. 87% vs. 93% (pZ0.01) and OS of 50% vs. 76% vs. 88% (pZ0.04), respectively. Tumor stage T1a vs. T1b vs. T2 were associated with 2-year LC of 97% vs. 95% vs. 92% (pZ0.05), DSS of 93% vs. 94% vs. 83% (pZ0.001) and OS of 89% vs. 86% vs. 76% (pZ0.03). Conclusion: The algorithm for patient-adapted treatment selection adopted in our center allows for effective and safe lung SABR. Results from our large cohort support previously reported improved outcomes of lung SABR with dose escalation. Author Disclosure: H. Bahig: Invited speaker Accuray symposium; Accuray. E.J. Filion: Invited speaker Accuray symposium 22-09-2013; Accuray. T. Vu: None. L. Lambert: None. D. Mathieu: None. D. Roberge: Invited speaker Accuray symposium 22-09-2013; Accuray. M. Bouchard: None. C. Lavoie: None. D. Beliveau-Nadeau: None. J. Prenovault: None. M. Campeau: None.
Lung treatment, had no history of previous thoracic radiation and a minimum of 12 months follow-up. 12 patients had synchronous MPLC, 14 had metachronous, and 1 had both. Toxicity was prospectively graded per CTCAE v3.0. The Kaplan-Meier method was used to estimate local failure (LF), disease-free survival (DFS), progression- free survival (PFS), and overall survival (OS) (all time-to-event endpoints were defined as the time from treatment initiation to event or the day of last follow-up). For survival outcomes potential associations were assessed in univariate and multivariate analyses using the Cox proportional hazards model. Based on P values 0.10 in univariate analyses, and clinical relevance, multivariate analysis was performed using a stepwise regression model to identify variables that have an effect (2-sided P value 0.05) on survival outcomes. Results: Median follow-up was 36.5 (range, 12.2-87.2) months. Median age of patients at first diagnosis was 76 years (range, 57 - 86). 25 patients received two SBRT courses, 1 had three courses, and 1 had four. Of the 27 patients, 23 had pathological diagnosis of lung cancer. In total, 57 lesions were treated by SBRT in this cohort of patients [median dose/ fraction of 48 Gy/ 4 fractions (range, 60 Gy/ 8 fractions-30 Gy/ 5 fractions)]. 47% of these lesions (nZ27) had biopsy proven lung cancer. Local control rate at 3 years was 86%. Three-year DFS and OS were 63% and 67%, respectively. On univariate analysis patients with metachronous MPLC [HR: 0.25 (95% CI; 0.07-0.92, pZ0.03) and T1 tumors [HR: 0.18 (95% CI; 0.050.66, pZ0.009) had significantly better OS. On multivariate analysis only metachronous MPLC [HR: 0.18 (95% CI; 0.05-0.66, pZ0.01) retained significance on OS. Acute toxicity grade 2 was reported in 5 patients (1 patient with grade 2 fatigue and 4 with grade 2 pneumonitis) and 2 patients had late toxicities grade 2 (G2 chest wall pain, G3 dysphagia). None of the patients developed grade 3 pneumonitis. Conclusion: SBRT appears to be effective and safe for the management of MPLC. Patients should be followed indefinitely following SBRT as further second primary cancers may be managed with SBRT. Author Disclosure: A. Dayyat: None.
3106 Risk Adapted Radiation Therapy for Thymoma: A Single-Institution 30 Year Review N. Lalani,1 N. Safieddine,2 D. Hwang,2 S. Keshavjee,2 A. Bezjak,1 and A.M. Brade1; 1Princess Margaret Cancer Centre, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada Purpose/Objective(s): Resection is the standard of care for localized thymic malignancies. Post-operative radiation therapy (RT) is often employed to prevent local recurrence, but the optimal dose has not yet been established. Personalized therapy using risk-adapted low-dose RT (LD) for select patients may provide equivalent local control and decreased toxicity compared to conventional high-dose regimens (HD). Our institution employs such a risk-adapted strategy and we present here our long term results. Materials/Methods: Radiation and surgical oncology databases from a single tertiary care institution were queried from 1980-2012. Retrospective analyses using electronic patient records were performed to obtain clinical and demographic data. Actuarial analyses and correlation of outcomes with clinical variables were performed. The mean follow-up was 9.4 years (0.5-25.5). Results: One hundred fifty-seven patients treated with post-operative RT from 1980-2012 were identified. Of these, 104 (66%) were treated with LD (36-42 Gy) in a risk-adapted fashion while the remaining 53 (44%) received HD (42-66Gy). The majority of patients were Masaoka-Koga (MK) stage II: 66 (42%) or III: 61 (39%) and WHO grade B1: 30 (19%), B2: 30 (19%) or B3: 30 (19%). Complete surgical resection was obtained in 79 (50%) of patients. A total of 49 (31%) of patients experienced relapse: 22 (14%) regional, 8 (5%) local, and 6 (4%) distant. Patients receiving LD experienced a local relapse rate of 4% compared to 7% in the HD group (pZ0.035). LD and MK stage were predictive of local recurrence (pZ0.035). Conclusion: Risk-adapted post-operative RT may improve the therapeutic ratio for patients with thymoma. Long-term randomized trials are required to further identify patients best suited to this approach. Author Disclosure: N. Lalani: None. N. Safieddine: None. D. Hwang: None. S. Keshavjee: None. A. Bezjak: None. A.M. Brade: None.
3107 Safety and Outcomes of Multiple Courses of Stereotactic Body Radiation Therapy to the Lung C.V. Sole, A.J. Hope, A. Dayyat, A. Sun, J. Cho, O. Wong, L. Lee, A.M. Brade, A. Bezjak, and M.E. Giuliani; Princess Margaret Cancer Centre/University of Toronto, ON, Canada Purpose/Objective(s): Patients with multiple primary lung cancers (MPLC) present a therapeutic challenge. We evaluated the role of stereotactic body radiation therapy (SBRT) in this population in terms of efficacy and safety. Materials/Methods: A prospective lung SBRT registry was retrospectively explored to identify patients who were treated with more than one SBRT
3108 Does Motion Management Technique for Lung SBRT Influence Local Control: A Single-Institutional Experience Comparing Abdominal Compression to Breath Hold Technique G.M. Videtic, N.M. Woody, C.A. Reddy, T. Djemil, and K.L. Stephans; Cleveland Clinic, Cleveland, OH Purpose/Objective(s): Since 2003, we have used abdominal compression (COMP) for lung stereotactic body radiation therapy (SBRT). In 11/2009, breath hold technique by automatic breath control (ABC) device was introduced especially for fit oligometastatic patients (pts). We now compare local failure (LF) results for COMP versus ABC. Materials/Methods: Our IRB-approved SBRT registry was queried for pts. treated for either a primary lung cancer (PRIME) or an oligometastatic (OLIGO) diagnosis with a minimum 6 months follow-up. SBRT was delivered by a stereotactic-specific LINAC platform with vacuum-bag based immobilization, and infrared-based X-ray positioning system+/CBCT for image-guidance. With COMP, tumor excursion was limited to <1cm and the ITV was created one of two way dependent on treatment era: 1. Fused GTV excursion CTs from free breathing, fixed inhale and exhale travel or 2. by 4DCT, with PTV created from the MIP ITV after adding a 5mm margin. With ABC, 3 serial CT image sets confirmed target immobilization, with the PTV generated after 5 mm was added to the static GTV. SBRT was delivered either with dynamic arcs or step-and-shoot intensityemodulated beams. SBRT dose/fractionation schedules reflected treatment era, tumor location, clinician preference, and trial-based experience. LF was defined as progressive and increasing CT scan abnormalities confirmed by progressive and incremental increases in a lesion’s SUVs on serial PET imaging, with or without biopsy. Results: For the interval 10/2003 to 7/2014, 873 pts with 931 lesions were treated. Overall pt. characteristics were: 455 (52.1%) female; 83.9% Caucasian; median age 73 years (range 37-97); median KPS 80 (range 40100); median BMI 26.2 (range 12.1-56.3). Overall tumor characteristics were: median tumor size 2.2 cm (range 0.7-10.0); median PET SUVmax