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Stereotactic Body Radiation Therapy for Large Hepatocellular Carcinomas
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Volume 99 Number 2S Supplement 2017 underwent prior liver-directed therapy (86.2% underwent 0-1 prior treatments and 13.8% underwent 2+ prior treatments). The median treated tumor number was 1 (range 1-3). The median largest tumor size was 3.1 cm (range 1.1-8.2 cm). The most commonly delivered dose was 50 Gy given in 5 fractions (45% of patients). Fifty-two percent of patients received a biologically effective dose >75 Gy. All but 1 patient completed treatment as planned. One patient had Grade 3+ acute toxicity (hepatic failure by CTCAE v4.0 criteria). The median follow up was 11.5 months. The median PFS and OS rates were 13.4 months (95% CI 6.6-20.6) and 28.3 months (95% CI 22.2-Non-Estimable), respectively. FFLP for all patients at 1 and 2 years was 82% (95% CI 69-91) and 46% (95% CI 21-69), respectively. The 1 and 2 year FFLP was numerically higher for patients treated with a biologically effective dose >75 Gy (87% vs. 75% and 64% vs. 19%, respectively), however, this difference was not maintained across the entire observation period (log-rank pZ0.12). Conclusion: HIGRT results in high rates of local control with acceptable treatment related toxicity for patients with unresectable HCC. Further analyses of clinical parameters and the impact of dose on patient outcomes is forthcoming, including late liver toxicity and outcomes based on pretreatment liver function. We are currently conducting a randomized, prospective trial to evaluate the role of HIGRT in patients with unresectable, non-metastatic HCC. Author Disclosure: S.J. Stephens: None. Y.A. Abdelazim: None. S.M. Thomas: None. J.K. Salama: Employee; Duke University School of Medicine. Research Grant; BMS, Celldex, GSK, Immunocore, Merck, AbbVie. ; ARS-ACR. D.J. Godfrey: Employee; Duke University. Royalty; Advances in Medical Physics, Vols 4-6. Patent/License Fees/Copyright; Advances in Medical Physics, Vols 4-6, US Patent #6,970,531. Manage review process for submitted scientific manuscripts; Journal of Medical Physics. C.G. Willett: Employee; Mary Sunday. Honoraria; Oakstone Institute. B. Czito: Research Grant; Abbvie. ; ASTRO. M. Palta: Honoraria; Oakstone, UptoDate.
2454 Stereotactic Body Radiation Therapy for Large Hepatocellular Carcinomas J.S. Suri,1 H.C. Qiu Jr,2 D.P. Bergsma,3 K.Y. Usuki,4 and A.W. Katz4; 1 University of Rochester, Rochester, NY, 2Wilmot Cancer Institute, University of Rochester, Rochester, NY, 3University of Rochester Medical Center, Rochester, NY, 4Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY Purpose/Objective(s): To evaluate efficacy and safety of Stereotactic Body Radiation Therapy (SBRT) for hepatocellular carcinoma (HCC) patients with primary lesion at least 5 cm in diameter. Materials/Methods: Through an IRB-approved retrospective review of departmental records, we identified 194 patients treated with SBRT for HCC at our institution from 2004-2015. After reviewing all available radiographic and clinical records, 36 patients were found to have a primary lesion greater than or equal to 5 cm in maximum diameter. We recorded radiographic response and treatment toxicities (using CTCAE 3.0). Results: Gender distribution was 32 (89%) male and 4 (11%) female with median age 71 (range 53-93) years at the time of diagnosis and SBRT. Median Zubrod performance score was 1 (range 0-2). Among 35 patients with calculable Child Pugh classification, 23 (66%), 10 (28%), and 2 (6%) of patients were class A, B, and C respectively. Median lesion size was 6 (range 5-14) cm. Radiotherapy was delivered using stereotactic technique and prescribed to isocenter with a median dose of 42.5 (range 30 to 62.5) Gy. All patients were treated in either 5 or 10 total fractions. Assuming an alpha/beta ratio of 10, median biologically equivalent dose (BED) for all patients was 72 (range 39-141) Gy. SBRT was the initial treatment modality for 29 (81%) patients, while 19% of patients had undergone prior treatment [transarterial chemoembolization (TACE) in 4 (11%) patients and radiofrequency ablation (RFA) in 3 (8%) patients]. The 3 month local radiographic response was complete in 6%,
partial in 47%, stable in 38%, and progressive disease in 9% of patients (2 were unknown). 58% of patients experienced no treatment toxicity, 19% experienced grade 1 toxicity, and 14% experienced grade 2 toxicity (unknown for 3 patients). No acute or late grade 3 radiation toxicities were reported. Conclusion: SBRT is a safe and effective treatment modality for patients with large HCC lesions, especially if they are not amendable to other therapeutic interventions. Author Disclosure: J.S. Suri: None. H.C. Qiu: None. D.P. Bergsma: None. K.Y. Usuki: None. A.W. Katz: Employee; Highland Hospital.
2455 Intratreatment FDG-PET Imaging to Predict Radiation Induced Esophagitis During Chemoradiation Therapy for Esophageal Cancer D.J. Tandberg,1 Y. Cui,1 J.C. Hong,1 B. Ackerson,1 B. Czito,1 C.G. Willett,1 and M. Palta2; 1Duke University Medical Center, Durham, NC, 2Department of Radiation Oncology, Duke University Medical Center, Durham, NC Purpose/Objective(s): In this analysis we evaluated if changes in esophageal metabolic uptake on intra-treatment fluorodeoxyglucose positron emission tomography (FDG-PET) during chemoradiotherapy (CRT) for esophageal cancer correlates with the development of clinically significant radiation (RT)-induced esophagitis. Materials/Methods: From 2012 to 2016, 60 patients with esophageal cancer were prospectively enrolled and underwent PET/CT scans before therapy and after 30-36 Gy. All patients received carboplatin/paclitaxelbased CRT. Maximum esophagitis grade was recorded using the RTOG/ EORTC scale. To determine the change in esophageal metabolic activity during CRT an esophageal region of interest (ROI) was contoured at the same esophageal location on the pre-treatment and intra-treatment PET/ CT scans. The esophageal ROI consisted of 9 contiguous slices of the esophagus within the radiation field but separate from the hypermetabolic primary tumor. Rigid registration with manual edits for anatomical changes was performed to ensure the ROI was contoured at the same esophageal location on the pre-treatment and intra-treatment PET/CT scans. The relative change in peak standard uptake value (SUVpeak) within the esophageal ROI from pre-treatment to intra-treatment PET was compared between patients with grade 0-1 esophagitis and grade > 2 esophagitis using the Mann-Whitney test and binary logistic regression. Results: Of 60 patients enrolled, 45 were evaluated. Reasons for exclusion included: did not complete both scans (nZ8), re-irradiation within previous RT field (nZ3), and feeding tube/stent prior to CRT (nZ4). Forty-one patients were treated with definitive or neoadjuvant CRT and 4 palliative CRT. The median delivered RT dose was 46.8 Gy (range, 37.8-50.4 Gy). Grade 2 or greater esophagitis developed in 24 patients (53%) at a median of 28 days following CRT initiation. There was no significant difference in esophageal dosimetric parameters (max, mean, V35 Gy and V50 Gy) between patients with grade 0-1 and grade > 2 esophagitis. Among all patients the increase in esophageal SUVpeak (median) from pre-treatment to intra-treatment PET was 19% (interquartile range [IQR] -3.4-64%). The change in SUVpeak was significantly greater among patients with grade > 2 esophagitis compared to patients with grade 0-1 esophagitis, 40% (IQR 4.2-89%) vs -1.4% (IQR -8.7-45%), respectively (pZ0.02). On univariate binary logistic regression analysis including clinical and dosimetric parameters, SUVpeak (HR 1.02, pZ0.046) was the only significant variable. Conclusion: Esophageal SUVpeak increased on intra-treatment PET/CT performed during CRT for esophageal cancer and may predict for clinically significant RT-induced esophagitis. Author Disclosure: D.J. Tandberg: None. Y. Cui: None. J.C. Hong: None. B. Ackerson: None. B. Czito: Research Grant; Abbvie. ; ASTRO. C.G. Willett: Employee; Mary Sunday. Honoraria; Oakstone Institute. M. Palta: Honoraria; Oakstone, UptoDate.
Volume 99 Number 2S Supplement 2017 underwent prior liver-directed therapy (86.2% underwent 0-1 prior treatments and 13.8% underwent 2+ prior treatments). The median treated tumor number was 1 (range 1-3). The median largest tumor size was 3.1 cm (range 1.1-8.2 cm). The most commonly delivered dose was 50 Gy given in 5 fractions (45% of patients). Fifty-two percent of patients received a biologically effective dose >75 Gy. All but 1 patient completed treatment as planned. One patient had Grade 3+ acute toxicity (hepatic failure by CTCAE v4.0 criteria). The median follow up was 11.5 months. The median PFS and OS rates were 13.4 months (95% CI 6.6-20.6) and 28.3 months (95% CI 22.2-Non-Estimable), respectively. FFLP for all patients at 1 and 2 years was 82% (95% CI 69-91) and 46% (95% CI 21-69), respectively. The 1 and 2 year FFLP was numerically higher for patients treated with a biologically effective dose >75 Gy (87% vs. 75% and 64% vs. 19%, respectively), however, this difference was not maintained across the entire observation period (log-rank pZ0.12). Conclusion: HIGRT results in high rates of local control with acceptable treatment related toxicity for patients with unresectable HCC. Further analyses of clinical parameters and the impact of dose on patient outcomes is forthcoming, including late liver toxicity and outcomes based on pretreatment liver function. We are currently conducting a randomized, prospective trial to evaluate the role of HIGRT in patients with unresectable, non-metastatic HCC. Author Disclosure: S.J. Stephens: None. Y.A. Abdelazim: None. S.M. Thomas: None. J.K. Salama: Employee; Duke University School of Medicine. Research Grant; BMS, Celldex, GSK, Immunocore, Merck, AbbVie. ; ARS-ACR. D.J. Godfrey: Employee; Duke University. Royalty; Advances in Medical Physics, Vols 4-6. Patent/License Fees/Copyright; Advances in Medical Physics, Vols 4-6, US Patent #6,970,531. Manage review process for submitted scientific manuscripts; Journal of Medical Physics. C.G. Willett: Employee; Mary Sunday. Honoraria; Oakstone Institute. B. Czito: Research Grant; Abbvie. ; ASTRO. M. Palta: Honoraria; Oakstone, UptoDate.
2454 Stereotactic Body Radiation Therapy for Large Hepatocellular Carcinomas J.S. Suri,1 H.C. Qiu Jr,2 D.P. Bergsma,3 K.Y. Usuki,4 and A.W. Katz4; 1 University of Rochester, Rochester, NY, 2Wilmot Cancer Institute, University of Rochester, Rochester, NY, 3University of Rochester Medical Center, Rochester, NY, 4Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY Purpose/Objective(s): To evaluate efficacy and safety of Stereotactic Body Radiation Therapy (SBRT) for hepatocellular carcinoma (HCC) patients with primary lesion at least 5 cm in diameter. Materials/Methods: Through an IRB-approved retrospective review of departmental records, we identified 194 patients treated with SBRT for HCC at our institution from 2004-2015. After reviewing all available radiographic and clinical records, 36 patients were found to have a primary lesion greater than or equal to 5 cm in maximum diameter. We recorded radiographic response and treatment toxicities (using CTCAE 3.0). Results: Gender distribution was 32 (89%) male and 4 (11%) female with median age 71 (range 53-93) years at the time of diagnosis and SBRT. Median Zubrod performance score was 1 (range 0-2). Among 35 patients with calculable Child Pugh classification, 23 (66%), 10 (28%), and 2 (6%) of patients were class A, B, and C respectively. Median lesion size was 6 (range 5-14) cm. Radiotherapy was delivered using stereotactic technique and prescribed to isocenter with a median dose of 42.5 (range 30 to 62.5) Gy. All patients were treated in either 5 or 10 total fractions. Assuming an alpha/beta ratio of 10, median biologically equivalent dose (BED) for all patients was 72 (range 39-141) Gy. SBRT was the initial treatment modality for 29 (81%) patients, while 19% of patients had undergone prior treatment [transarterial chemoembolization (TACE) in 4 (11%) patients and radiofrequency ablation (RFA) in 3 (8%) patients]. The 3 month local radiographic response was complete in 6%,
partial in 47%, stable in 38%, and progressive disease in 9% of patients (2 were unknown). 58% of patients experienced no treatment toxicity, 19% experienced grade 1 toxicity, and 14% experienced grade 2 toxicity (unknown for 3 patients). No acute or late grade 3 radiation toxicities were reported. Conclusion: SBRT is a safe and effective treatment modality for patients with large HCC lesions, especially if they are not amendable to other therapeutic interventions. Author Disclosure: J.S. Suri: None. H.C. Qiu: None. D.P. Bergsma: None. K.Y. Usuki: None. A.W. Katz: Employee; Highland Hospital.
2455 Intratreatment FDG-PET Imaging to Predict Radiation Induced Esophagitis During Chemoradiation Therapy for Esophageal Cancer D.J. Tandberg,1 Y. Cui,1 J.C. Hong,1 B. Ackerson,1 B. Czito,1 C.G. Willett,1 and M. Palta2; 1Duke University Medical Center, Durham, NC, 2Department of Radiation Oncology, Duke University Medical Center, Durham, NC Purpose/Objective(s): In this analysis we evaluated if changes in esophageal metabolic uptake on intra-treatment fluorodeoxyglucose positron emission tomography (FDG-PET) during chemoradiotherapy (CRT) for esophageal cancer correlates with the development of clinically significant radiation (RT)-induced esophagitis. Materials/Methods: From 2012 to 2016, 60 patients with esophageal cancer were prospectively enrolled and underwent PET/CT scans before therapy and after 30-36 Gy. All patients received carboplatin/paclitaxelbased CRT. Maximum esophagitis grade was recorded using the RTOG/ EORTC scale. To determine the change in esophageal metabolic activity during CRT an esophageal region of interest (ROI) was contoured at the same esophageal location on the pre-treatment and intra-treatment PET/ CT scans. The esophageal ROI consisted of 9 contiguous slices of the esophagus within the radiation field but separate from the hypermetabolic primary tumor. Rigid registration with manual edits for anatomical changes was performed to ensure the ROI was contoured at the same esophageal location on the pre-treatment and intra-treatment PET/CT scans. The relative change in peak standard uptake value (SUVpeak) within the esophageal ROI from pre-treatment to intra-treatment PET was compared between patients with grade 0-1 esophagitis and grade > 2 esophagitis using the Mann-Whitney test and binary logistic regression. Results: Of 60 patients enrolled, 45 were evaluated. Reasons for exclusion included: did not complete both scans (nZ8), re-irradiation within previous RT field (nZ3), and feeding tube/stent prior to CRT (nZ4). Forty-one patients were treated with definitive or neoadjuvant CRT and 4 palliative CRT. The median delivered RT dose was 46.8 Gy (range, 37.8-50.4 Gy). Grade 2 or greater esophagitis developed in 24 patients (53%) at a median of 28 days following CRT initiation. There was no significant difference in esophageal dosimetric parameters (max, mean, V35 Gy and V50 Gy) between patients with grade 0-1 and grade > 2 esophagitis. Among all patients the increase in esophageal SUVpeak (median) from pre-treatment to intra-treatment PET was 19% (interquartile range [IQR] -3.4-64%). The change in SUVpeak was significantly greater among patients with grade > 2 esophagitis compared to patients with grade 0-1 esophagitis, 40% (IQR 4.2-89%) vs -1.4% (IQR -8.7-45%), respectively (pZ0.02). On univariate binary logistic regression analysis including clinical and dosimetric parameters, SUVpeak (HR 1.02, pZ0.046) was the only significant variable. Conclusion: Esophageal SUVpeak increased on intra-treatment PET/CT performed during CRT for esophageal cancer and may predict for clinically significant RT-induced esophagitis. Author Disclosure: D.J. Tandberg: None. Y. Cui: None. J.C. Hong: None. B. Ackerson: None. B. Czito: Research Grant; Abbvie. ; ASTRO. C.G. Willett: Employee; Mary Sunday. Honoraria; Oakstone Institute. M. Palta: Honoraria; Oakstone, UptoDate.