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Salvage Radiation Therapy for Locoregionally Recurrent Non-Small Cell Lung Cancer After Surgical Resection
Poster Viewing E423
Volume 96 Number 2S Supplement 2016 patients with NSCLC demonstrated that doses up to 60 Gy in 15 fractions were well tolerated. This hypofractionated regimen has been adopted at our institution for patients who cannot receive standard of care treatment for their lung cancers. Materials/Methods: We report outcomes including survival, patterns of failure, and toxicity rates on patients with NSCLC who were not eligible for surgical resection, concurrent chemoradiation, or SABR, and were treated with a hypofractionated RT regimen with intensitymodulated radiation therapy (IMRT). Kaplan-Meier survival analysis was used to evaluate progression-free and overall survival, and competing risk analysis was used to evaluate in-field and locoregional failure. Results: Forty-two patients treated to 52.5 to 60 Gy in 15 fractions were included. The majority of patients (62%) had metastatic or recurrent disease. The median follow-up from treatment start was 13 months (interquartile range 6-18 months). All patients completed radiation therapy, receiving the total prescribed dose. Median survival was 15.1 months. Overall survival and progression-free survival rates at 1-year were 63% and 22.5%, respectively. Pattern of failure was predominantly distal, with only 2% of patients experiencing isolated in-field recurrence. Cumulative incidence of in-field failure at 6 and 12 months was 2.5% (95% CI 0.4-15.6) and 16.1% (95% CI 7.5-34.7), respectively. Cumulative incidence of locoregional failure at 6 and 12 months was 12.0% (95% CI 4.9-29.2) and 33.4% (95% CI 21.6-51.6), respectively. Cumulative incidence of distant failure at 6 and 12 months was 33.9% (95% CI 22.3-51.6) and 61.2% (95% CI 48.4-77.6), respectively. Risk of esophageal toxicity was associated with esophageal mean dose, maximal point dose, and D5cc. Risk of pneumonitis was associated with lung mean dose and V18 Gy. Conclusion: Hypofractionated radiation therapy without concurrent chemotherapy provides relatively favorable rates of early local control, and can serve as a safe, convenient and effective treatment alternative for patients with NSCLC who cannot tolerate standard of care treatment. Author Disclosure: Y. Qian: None. E. Pollom: None. B.Y. Durkee: None. R. von Eyben: None. M.F. Gensheimer: None. D.B. Shultz: None. M. Diehn: None. B.W. Loo: None.
3042 Salvage Radiation Therapy for Locoregionally Recurrent Non-Small Cell Lung Cancer After Surgical Resection E. Kim1 and J.S. Kim2; 1Seoul National University Bundang Hospital Gyeonggi-do, Korea, The Republic of Korea, 2Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnamsi, Korea, The Republic of Korea Purpose/Objective(s): Radiation therapy with or without chemotherapy is commonly used for isolated loco-regional recurrence of non-small cell lung cancer (NSCLC) after initial surgery. This study was undertaken to evaluate the outcomes and complications of curative radiation therapy for locoregionally recurrent NSCLC. Materials/Methods: Medical records of 57 patients who received curative radiation therapy for locoregionally recurrent NSCLC without distant metastasis after surgery from 2004 to 2014 were retrospectively reviewed. At the time of recurrence, the median age was 67 years (range 34-81 years), and most patients (84.2%) have good ECOG performance status. All patients initially received a curative intent operation, and the median disease-free interval was 14 months. For locoregionally recurrent lung cancer, 42 patients were treated with concurrent chemoradiation therapy (CCRT), and 15 patients with radiation therapy alone. Radiation dose ranged from 45 Gy to 70 Gy (median 66 Gy) by a three-dimensional conformal technique. Lung function change after radiation therapy was evaluated by comparing pulmonary function tests before and after radiation therapy.
Results: Median follow-up after recurrence was 20 months. Six patients showed a complete response, and 39 patients showed a partial response. The median survival was 30 months. Two-year locoregional recurrencefree survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS) and overall survival (OS) rate were 46.1%, 37.2%, 31.9%, and 65.1%, respectively. Eleven patients showed disease progression within the radiation field after radiation therapy. Pulmonary function decreased meaningfully after radiation therapy, and radiation pneumonitis of any grade was seen in 19 patients. In the multivariate analysis, age under 70 years was associated with good OS (P Z 0.047); concurrent chemoradiation therapy with good OS (P Z 0.014), and DFS (P Z 0.003); and single-station recurrence with good OS (P Z 0.01), DFS (P Z 0.022), and LRFS (P Z 0.01). Conclusion: Patients who have locoregionally recurrent NSCLC showed favorable survival outcomes with salvage radiation therapy. However, lung function should be carefully evaluated before and after radiation therapy. Young age, single site recurrence, and the use of CCRT were good prognostic factors of overall survival. In patients with good prognostic factors and suitable for curative radiation therapy, CCRT could be considered to improve treatment outcomes. Author Disclosure: E. Kim: None. J. Kim: None.
3043 Current Patterns of Care for Patients With Extensive Stage Small Cell Lung Cancer: Survey of US Radiation Oncologists on Their Recommendations Regarding Prophylactic Cranial Irradiation A. Jain,1 J. Luo,1 Y. Chen,1 M.A. Henderson,2 C.R. Thomas, Jr,1 and T. Mitin1; 1Oregon Health and Science University, Portland, OR, 2 Bay Area Cancer Center, Coos Bay, OR Purpose/Objective(s): Conflicting data from randomized clinical trials (Slotman et al., NEJM 2007 and Seto et al, JCO 2014, abstract) incite the debate over the appropriate use of prophylactic cranial irradiation (PCI) for patients with extensive stage small cell lung cancer (ES-SCLC) who achieve clinical response to systemic chemotherapy. Current NCCN guidelines are not fully aligned with available clinical evidence. The current pattern of practice among US radiation oncologists is unknown. We hypothesized that a better knowledge of individual clinical trials is associated with a higher chance of physicians deviating from NCCN guidelines. Materials/Methods: We have surveyed practicing US radiation oncologist via a short online questionnaire. Respondents’ characteristics and their self-rated knowledge base were analyzed for association with their treatment recommendations. Results: We received 475 responses from practicing US radiation oncologists. 90% of respondents recommend brain MRI imaging prior to initiation of PCI and 98% recommend PCI for patients with ES-SCLC after systemic chemotherapy. Half of respondents follow their patients with brain MRI imaging after completion of PCI. One-third of respondents prescribe memantine to patients undergoing PCI. Among the respondents, recent graduates (P Z 0.004) and physicians practicing in academic centers (P Z 0.005) are more likely to prescribe memantine during PCI. Self-rated knowledge base was not associated with any treatment recommendations. Conclusion: We thank physicians who participated in this online survey. Our analysis revealed that among the respondents, there was a very high adherence to current NCCN guidelines, which recommend universal PCI and obtaining brain MRI prior to initiation of PCI for ES-SCLC patients with clinical response to systemic chemotherapy. These guidelines and practice patterns are not supported by clinical evidence, since patients on EORTC trial 22993-08993 did not undergo brain MRI prior to PCI, and the Japanese randomized trial has shown a possible detrimental effect of PCI on overall survival when brain MRI was incorporated. A critical re-
Volume 96 Number 2S Supplement 2016 patients with NSCLC demonstrated that doses up to 60 Gy in 15 fractions were well tolerated. This hypofractionated regimen has been adopted at our institution for patients who cannot receive standard of care treatment for their lung cancers. Materials/Methods: We report outcomes including survival, patterns of failure, and toxicity rates on patients with NSCLC who were not eligible for surgical resection, concurrent chemoradiation, or SABR, and were treated with a hypofractionated RT regimen with intensitymodulated radiation therapy (IMRT). Kaplan-Meier survival analysis was used to evaluate progression-free and overall survival, and competing risk analysis was used to evaluate in-field and locoregional failure. Results: Forty-two patients treated to 52.5 to 60 Gy in 15 fractions were included. The majority of patients (62%) had metastatic or recurrent disease. The median follow-up from treatment start was 13 months (interquartile range 6-18 months). All patients completed radiation therapy, receiving the total prescribed dose. Median survival was 15.1 months. Overall survival and progression-free survival rates at 1-year were 63% and 22.5%, respectively. Pattern of failure was predominantly distal, with only 2% of patients experiencing isolated in-field recurrence. Cumulative incidence of in-field failure at 6 and 12 months was 2.5% (95% CI 0.4-15.6) and 16.1% (95% CI 7.5-34.7), respectively. Cumulative incidence of locoregional failure at 6 and 12 months was 12.0% (95% CI 4.9-29.2) and 33.4% (95% CI 21.6-51.6), respectively. Cumulative incidence of distant failure at 6 and 12 months was 33.9% (95% CI 22.3-51.6) and 61.2% (95% CI 48.4-77.6), respectively. Risk of esophageal toxicity was associated with esophageal mean dose, maximal point dose, and D5cc. Risk of pneumonitis was associated with lung mean dose and V18 Gy. Conclusion: Hypofractionated radiation therapy without concurrent chemotherapy provides relatively favorable rates of early local control, and can serve as a safe, convenient and effective treatment alternative for patients with NSCLC who cannot tolerate standard of care treatment. Author Disclosure: Y. Qian: None. E. Pollom: None. B.Y. Durkee: None. R. von Eyben: None. M.F. Gensheimer: None. D.B. Shultz: None. M. Diehn: None. B.W. Loo: None.
3042 Salvage Radiation Therapy for Locoregionally Recurrent Non-Small Cell Lung Cancer After Surgical Resection E. Kim1 and J.S. Kim2; 1Seoul National University Bundang Hospital Gyeonggi-do, Korea, The Republic of Korea, 2Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnamsi, Korea, The Republic of Korea Purpose/Objective(s): Radiation therapy with or without chemotherapy is commonly used for isolated loco-regional recurrence of non-small cell lung cancer (NSCLC) after initial surgery. This study was undertaken to evaluate the outcomes and complications of curative radiation therapy for locoregionally recurrent NSCLC. Materials/Methods: Medical records of 57 patients who received curative radiation therapy for locoregionally recurrent NSCLC without distant metastasis after surgery from 2004 to 2014 were retrospectively reviewed. At the time of recurrence, the median age was 67 years (range 34-81 years), and most patients (84.2%) have good ECOG performance status. All patients initially received a curative intent operation, and the median disease-free interval was 14 months. For locoregionally recurrent lung cancer, 42 patients were treated with concurrent chemoradiation therapy (CCRT), and 15 patients with radiation therapy alone. Radiation dose ranged from 45 Gy to 70 Gy (median 66 Gy) by a three-dimensional conformal technique. Lung function change after radiation therapy was evaluated by comparing pulmonary function tests before and after radiation therapy.
Results: Median follow-up after recurrence was 20 months. Six patients showed a complete response, and 39 patients showed a partial response. The median survival was 30 months. Two-year locoregional recurrencefree survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS) and overall survival (OS) rate were 46.1%, 37.2%, 31.9%, and 65.1%, respectively. Eleven patients showed disease progression within the radiation field after radiation therapy. Pulmonary function decreased meaningfully after radiation therapy, and radiation pneumonitis of any grade was seen in 19 patients. In the multivariate analysis, age under 70 years was associated with good OS (P Z 0.047); concurrent chemoradiation therapy with good OS (P Z 0.014), and DFS (P Z 0.003); and single-station recurrence with good OS (P Z 0.01), DFS (P Z 0.022), and LRFS (P Z 0.01). Conclusion: Patients who have locoregionally recurrent NSCLC showed favorable survival outcomes with salvage radiation therapy. However, lung function should be carefully evaluated before and after radiation therapy. Young age, single site recurrence, and the use of CCRT were good prognostic factors of overall survival. In patients with good prognostic factors and suitable for curative radiation therapy, CCRT could be considered to improve treatment outcomes. Author Disclosure: E. Kim: None. J. Kim: None.
3043 Current Patterns of Care for Patients With Extensive Stage Small Cell Lung Cancer: Survey of US Radiation Oncologists on Their Recommendations Regarding Prophylactic Cranial Irradiation A. Jain,1 J. Luo,1 Y. Chen,1 M.A. Henderson,2 C.R. Thomas, Jr,1 and T. Mitin1; 1Oregon Health and Science University, Portland, OR, 2 Bay Area Cancer Center, Coos Bay, OR Purpose/Objective(s): Conflicting data from randomized clinical trials (Slotman et al., NEJM 2007 and Seto et al, JCO 2014, abstract) incite the debate over the appropriate use of prophylactic cranial irradiation (PCI) for patients with extensive stage small cell lung cancer (ES-SCLC) who achieve clinical response to systemic chemotherapy. Current NCCN guidelines are not fully aligned with available clinical evidence. The current pattern of practice among US radiation oncologists is unknown. We hypothesized that a better knowledge of individual clinical trials is associated with a higher chance of physicians deviating from NCCN guidelines. Materials/Methods: We have surveyed practicing US radiation oncologist via a short online questionnaire. Respondents’ characteristics and their self-rated knowledge base were analyzed for association with their treatment recommendations. Results: We received 475 responses from practicing US radiation oncologists. 90% of respondents recommend brain MRI imaging prior to initiation of PCI and 98% recommend PCI for patients with ES-SCLC after systemic chemotherapy. Half of respondents follow their patients with brain MRI imaging after completion of PCI. One-third of respondents prescribe memantine to patients undergoing PCI. Among the respondents, recent graduates (P Z 0.004) and physicians practicing in academic centers (P Z 0.005) are more likely to prescribe memantine during PCI. Self-rated knowledge base was not associated with any treatment recommendations. Conclusion: We thank physicians who participated in this online survey. Our analysis revealed that among the respondents, there was a very high adherence to current NCCN guidelines, which recommend universal PCI and obtaining brain MRI prior to initiation of PCI for ES-SCLC patients with clinical response to systemic chemotherapy. These guidelines and practice patterns are not supported by clinical evidence, since patients on EORTC trial 22993-08993 did not undergo brain MRI prior to PCI, and the Japanese randomized trial has shown a possible detrimental effect of PCI on overall survival when brain MRI was incorporated. A critical re-