- Email: [email protected]
Safety and Tolerability of Liver Re-Irradiation
Poster Viewing Abstracts E171
Volume 99 Number 2S Supplement 2017
2411
2412
Diagnostic Value of Postchemoradiation Therapy 18 F-FDG PET/CT for Metastasis Identification in Locally Advanced Esophageal Cancer M. Marquardt,1 J.M. Watkins,2 G. Clamon,3 K. Parekh,3 J. Buatti,1 and C.M. Anderson1; 1Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, 2University of Iowa Hospitals & Clinics, Iowa City, IA, 3University of Iowa, Iowa City, IA
Safety and Tolerability of Liver Re-Irradiation S. McDuff,1 K. Remillard,1 J.Y. Wo,1 A. Raldow,2 J.A. Wolfgang,3 and T.S. Hong4; 1Massachusetts General Hospital, Boston, MA, 2Harvard Radiation Oncology Program, Boston, MA, 3Massachusetts General Hospital, Harvard Medical School, Boston, MA, 4Massachusetts General Hospital and Harvard Medical School, Boston, MA
Purpose/Objective(s): The management of locally advanced esophageal cancer involves a multimodality approach, including chemotherapy, radiotherapy, and possible esophagectomy. 18F-FDG PET/CT is variably used for restaging after chemoradiotherapy (CRT), and PET/CT value in the post-CRT setting is not clearly defined. This study investigated the value of PET/CT in identifying metastatic disease following pre-operative or definitive CRT, with the hypotheses that PET/CT specificity should be high, but sensitivity will be lower based on continued development of new metastases after PET/CT imaging. Materials/Methods: Locally advanced esophageal cancer patients undergoing CRT from 2000-2014 with post-CRT PET/CT were included in this study. The post-treatment PET/CT accuracy was assessed throughout available patient follow-up, with confirmation of new distant metastases versus benign findings through repeat imaging or pathologic assessment after PET/CT. Equivocal scans were designated positive if reaction to the results included further testing. To compare PET/CT metastatic performance under multiple assumptions, accuracy values were calculated without a defined post-imaging endpoint, and then recalculated using 3 and 6 month endpoints after post-treatment PET/CT. Results: Eighty-three patients met inclusion criteria. Median follow-up was 14 months (range: 1-72 months). Median time from CRT end to PET/ CT was 15 days (range: 4-29 days). Forty patients (48.2%) developed metastatic disease following CRT, with a median time to diagnosis of metastasis of 4.1 months (range: 0-45.8 months). Bone, liver, and lung were the most common sites of metastasis. Initial restaging PET/CT was positive for metastasis in 13 patients (15.7%), with confirmation in 9 patients (69.2%). Esophagectomy was subsequently cancelled in 8 of those patients initially considered for curative-intent resection. Four additional patients had intraoperative identification of distant metastasis not seen on restaging PET/CT (13 day median interval between imaging and surgery). The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the restaging PET/CT for detecting metastasis were 22.0%, 90.5%, 69.2%, and 54.3%, respectively. Values calculated using 3 and 6-month times to evaluation are listed in the Table. Conclusion: Initial restaging PET/CT changed planned therapy in 9.6% of patients. Specificity of metastasis detection is high. The sensitivity of the restaging PET/CT is low, and patients continue to be at high risk for metastatic disease beyond 3 months from imaging.
Purpose/Objective(s): Survival of patients with progressive primary or secondary liver cancer is poor, with death frequently associated with liver failure. Liver re-irradiation is a potential salvage option; however, reirradiation is not routinely offered given concern for radiation-induced liver disease (RILD). We examined the safety and tolerability of a second course of liver radiation. Materials/Methods: Patients with prior liver radiation who underwent repeat radiation for recurrent primary or metastatic liver lesions at our institution between 6/2008 and 12/2016 were included. Patients were monitored weekly with physical examination and laboratory studies during radiation and presented for follow-up at 3-6 weeks after completion of radiation and then every 3-6 months to monitor for progressive disease. Clinical and treatment-related factors including performance status, ChildPugh score, prior systemic and liver-directed therapy, and toxicity were evaluated. Patients were evaluated for any evidence of “classic” RILD or “non-classic” RILD. Results: 49 patients were included: 19 had HCC, 7 had intrahepatic cholangiocarcinoma, and 23 had metastatic liver disease (5 gastroesophageal, 2 pancreatic, 12 colorectal, and 4 other). Mean age at re-treatment was 68.7 years (range 43-90) and mean ECOG performance status was 1 (range 0-2). 6 patients in the cohort went on to receive a 3rd course of radiation to the liver; however only the first retreatment course was included in the analysis. Prior treatments included non-radiation liver directed therapy (surgery nZ18, TACE nZ4, RFA nZ3, microwave/ cryoablation nZ4), biologic therapy (nZ18) and chemotherapy (nZ32). Initial RT modality was protons (nZ29), photons (IMRT or 3D conformal, nZ7) and SBRT (nZ13). 5 patients received concurrent chemotherapy during liver retreatment. Mean interval from initial RT to first re-treatment was 411 days (range 61-1668 days). Re-treatment was performed with protons (nZ5), photons (nZ17), and SBRT (nZ27). Treatment was delivered to the same site (nZ12), a different site (nZ32) or a combination (nZ5) for the second course. Several fractionation schemes at retreatment were employed; most patients received 5-6 fractions (nZ33) or 15 fractions (nZ12) and doses ranged from 180 to 1000 cGy per fraction. Mean BED2 (a/bZ10) were 76.93 and 77.60 for initial treatment and retreatment, respectively. Mean Liver-GTV volume was 1589cc and LiverGTV Dmean BED2 (a/bZ3) was 9.9 Gy at re-treatment. 1 patient met criteria for “non-classic” RILD demonstrating significant metabolic derangements in the absence of progressive disease. Another 6 patients exhibited metabolic derangements in the presence of progressive intrahepatic disease burden. Conclusion: Re-irradiation of recurrent primary or metastatic liver lesions was overall safe and well-tolerated in our cohort. Additional studies are needed to establish treatment guidelines and proper dosing. Author Disclosure: S. McDuff: None. K. Remillard: None. J.Y. Wo: None. A. Raldow: None. J.A. Wolfgang: None. T.S. Hong: Research Grant; Novartis, Taiho.
Abstract 2411; Table Initial Restaging PET/CT Metastatic Performance by Defined Times to Evaluation Sensitivity (%) 3 month time to Evaluation 6 month time to Evaluation Overall (without specified endpoint)
56.3 37.5 22.0
Specificity (%) 94.0 92.0 90.5
PPV (%) 69.2 69.2 69.2
NPV (%) 89.9 75.4 54.3
2413 Author Disclosure: M. Marquardt: None. J.M. Watkins: None. G. Clamon: Research Grant; Merck. Stock; Pfizer. K. Parekh: None. J. Buatti: None. C.M. Anderson: Employee; University of Iowa College of Nursing, University of Iowa Hospitals & Clinics. Help plan the annual educational meeting; Iowa Society of Therapeutic Radiation Oncology. Enrolling patients on industry-sponsored clinical trial, discussing research related to trial drug with the company; Galera Therapeutics,Inc. Involved in lobbying.
Adjuvant Radiation Therapy for T4 Nonrectal Colon Adenocarcinoma Provides a Cause-Specific Survival Advantage: A SEER Database Analysis C. McLaughlin,1 N.K. Kim,2 D. Bandyopadhyay,2 X. Deng,2 B. Kaplan,1 K. Matin,1 and E.C. Fields1; 1VCU Massey Cancer Center, Richmond, VA, 2 Virginia Commonwealth University, Richmond, VA Purpose/Objective(s): Radiotherapy (RT)is commonly used in the management of locally advanced rectal adenocarcinoma, to improve locoregional control and potentially even overall survival. While there is no level
Volume 99 Number 2S Supplement 2017
2411
2412
Diagnostic Value of Postchemoradiation Therapy 18 F-FDG PET/CT for Metastasis Identification in Locally Advanced Esophageal Cancer M. Marquardt,1 J.M. Watkins,2 G. Clamon,3 K. Parekh,3 J. Buatti,1 and C.M. Anderson1; 1Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, 2University of Iowa Hospitals & Clinics, Iowa City, IA, 3University of Iowa, Iowa City, IA
Safety and Tolerability of Liver Re-Irradiation S. McDuff,1 K. Remillard,1 J.Y. Wo,1 A. Raldow,2 J.A. Wolfgang,3 and T.S. Hong4; 1Massachusetts General Hospital, Boston, MA, 2Harvard Radiation Oncology Program, Boston, MA, 3Massachusetts General Hospital, Harvard Medical School, Boston, MA, 4Massachusetts General Hospital and Harvard Medical School, Boston, MA
Purpose/Objective(s): The management of locally advanced esophageal cancer involves a multimodality approach, including chemotherapy, radiotherapy, and possible esophagectomy. 18F-FDG PET/CT is variably used for restaging after chemoradiotherapy (CRT), and PET/CT value in the post-CRT setting is not clearly defined. This study investigated the value of PET/CT in identifying metastatic disease following pre-operative or definitive CRT, with the hypotheses that PET/CT specificity should be high, but sensitivity will be lower based on continued development of new metastases after PET/CT imaging. Materials/Methods: Locally advanced esophageal cancer patients undergoing CRT from 2000-2014 with post-CRT PET/CT were included in this study. The post-treatment PET/CT accuracy was assessed throughout available patient follow-up, with confirmation of new distant metastases versus benign findings through repeat imaging or pathologic assessment after PET/CT. Equivocal scans were designated positive if reaction to the results included further testing. To compare PET/CT metastatic performance under multiple assumptions, accuracy values were calculated without a defined post-imaging endpoint, and then recalculated using 3 and 6 month endpoints after post-treatment PET/CT. Results: Eighty-three patients met inclusion criteria. Median follow-up was 14 months (range: 1-72 months). Median time from CRT end to PET/ CT was 15 days (range: 4-29 days). Forty patients (48.2%) developed metastatic disease following CRT, with a median time to diagnosis of metastasis of 4.1 months (range: 0-45.8 months). Bone, liver, and lung were the most common sites of metastasis. Initial restaging PET/CT was positive for metastasis in 13 patients (15.7%), with confirmation in 9 patients (69.2%). Esophagectomy was subsequently cancelled in 8 of those patients initially considered for curative-intent resection. Four additional patients had intraoperative identification of distant metastasis not seen on restaging PET/CT (13 day median interval between imaging and surgery). The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the restaging PET/CT for detecting metastasis were 22.0%, 90.5%, 69.2%, and 54.3%, respectively. Values calculated using 3 and 6-month times to evaluation are listed in the Table. Conclusion: Initial restaging PET/CT changed planned therapy in 9.6% of patients. Specificity of metastasis detection is high. The sensitivity of the restaging PET/CT is low, and patients continue to be at high risk for metastatic disease beyond 3 months from imaging.
Purpose/Objective(s): Survival of patients with progressive primary or secondary liver cancer is poor, with death frequently associated with liver failure. Liver re-irradiation is a potential salvage option; however, reirradiation is not routinely offered given concern for radiation-induced liver disease (RILD). We examined the safety and tolerability of a second course of liver radiation. Materials/Methods: Patients with prior liver radiation who underwent repeat radiation for recurrent primary or metastatic liver lesions at our institution between 6/2008 and 12/2016 were included. Patients were monitored weekly with physical examination and laboratory studies during radiation and presented for follow-up at 3-6 weeks after completion of radiation and then every 3-6 months to monitor for progressive disease. Clinical and treatment-related factors including performance status, ChildPugh score, prior systemic and liver-directed therapy, and toxicity were evaluated. Patients were evaluated for any evidence of “classic” RILD or “non-classic” RILD. Results: 49 patients were included: 19 had HCC, 7 had intrahepatic cholangiocarcinoma, and 23 had metastatic liver disease (5 gastroesophageal, 2 pancreatic, 12 colorectal, and 4 other). Mean age at re-treatment was 68.7 years (range 43-90) and mean ECOG performance status was 1 (range 0-2). 6 patients in the cohort went on to receive a 3rd course of radiation to the liver; however only the first retreatment course was included in the analysis. Prior treatments included non-radiation liver directed therapy (surgery nZ18, TACE nZ4, RFA nZ3, microwave/ cryoablation nZ4), biologic therapy (nZ18) and chemotherapy (nZ32). Initial RT modality was protons (nZ29), photons (IMRT or 3D conformal, nZ7) and SBRT (nZ13). 5 patients received concurrent chemotherapy during liver retreatment. Mean interval from initial RT to first re-treatment was 411 days (range 61-1668 days). Re-treatment was performed with protons (nZ5), photons (nZ17), and SBRT (nZ27). Treatment was delivered to the same site (nZ12), a different site (nZ32) or a combination (nZ5) for the second course. Several fractionation schemes at retreatment were employed; most patients received 5-6 fractions (nZ33) or 15 fractions (nZ12) and doses ranged from 180 to 1000 cGy per fraction. Mean BED2 (a/bZ10) were 76.93 and 77.60 for initial treatment and retreatment, respectively. Mean Liver-GTV volume was 1589cc and LiverGTV Dmean BED2 (a/bZ3) was 9.9 Gy at re-treatment. 1 patient met criteria for “non-classic” RILD demonstrating significant metabolic derangements in the absence of progressive disease. Another 6 patients exhibited metabolic derangements in the presence of progressive intrahepatic disease burden. Conclusion: Re-irradiation of recurrent primary or metastatic liver lesions was overall safe and well-tolerated in our cohort. Additional studies are needed to establish treatment guidelines and proper dosing. Author Disclosure: S. McDuff: None. K. Remillard: None. J.Y. Wo: None. A. Raldow: None. J.A. Wolfgang: None. T.S. Hong: Research Grant; Novartis, Taiho.
Abstract 2411; Table Initial Restaging PET/CT Metastatic Performance by Defined Times to Evaluation Sensitivity (%) 3 month time to Evaluation 6 month time to Evaluation Overall (without specified endpoint)
56.3 37.5 22.0
Specificity (%) 94.0 92.0 90.5
PPV (%) 69.2 69.2 69.2
NPV (%) 89.9 75.4 54.3
2413 Author Disclosure: M. Marquardt: None. J.M. Watkins: None. G. Clamon: Research Grant; Merck. Stock; Pfizer. K. Parekh: None. J. Buatti: None. C.M. Anderson: Employee; University of Iowa College of Nursing, University of Iowa Hospitals & Clinics. Help plan the annual educational meeting; Iowa Society of Therapeutic Radiation Oncology. Enrolling patients on industry-sponsored clinical trial, discussing research related to trial drug with the company; Galera Therapeutics,Inc. Involved in lobbying.
Adjuvant Radiation Therapy for T4 Nonrectal Colon Adenocarcinoma Provides a Cause-Specific Survival Advantage: A SEER Database Analysis C. McLaughlin,1 N.K. Kim,2 D. Bandyopadhyay,2 X. Deng,2 B. Kaplan,1 K. Matin,1 and E.C. Fields1; 1VCU Massey Cancer Center, Richmond, VA, 2 Virginia Commonwealth University, Richmond, VA Purpose/Objective(s): Radiotherapy (RT)is commonly used in the management of locally advanced rectal adenocarcinoma, to improve locoregional control and potentially even overall survival. While there is no level