Course Of Palliative Radiotherapy Research Articles

Case – Long-term remission after repeated courses of palliative radiotherapy in a patient with metastatic MiT family translocation renal cell carcinoma

Case – Long-term remission after repeated courses of palliative radiotherapy in a patient with metastatic MiT family translocation renal cell carcinoma

Thirty-day mortality after palliative radiotherapy in advanced cancer patients: Optimizing end-of-life care in Asia.

Evidence-based guidelines recommend hypofractionated palliative radiotherapy (PRT); nonetheless, many patients receive prolonged course of PRT. To identify patients with limited benefits from PRT in end-of-life care, we evaluated the pattern of PRT at an Asian institution and factors associated with 30-day mortality after PRT (30dM). We retrospectively reviewed 228 patients who died after PRT in Yonsei Wonju Severance Christian hospital between October 2014 and March 2022. The associations between clinical factors and survival were assessed using the Cox proportional hazards method. Survival was analysed using the existing models to evaluate their performance in our cohort. The median PRT duration was 13 (IQR, 7-15) days. Only 11.4% of the patients were treated with hypofractionated radiotherapy. One-third of the patients (32.9%) could not complete PRT and 39 (17.1%) died during PRT. The 30dM was 31.6%. The median time from PRT to death was 17 (IQR, 11-23) days for the patients who died within 30 days. The number of involved organs (≤2 vs. >2; P < 0.001), albumin level (<3.3 vs. ≥3.3; P = 0.016), admission during PRT (P < 0.001), admission 3 months before PRT (P = 0.036) and ICU care during PRT (P < 0.001) were prognostic factors. A comparison of survival based on the existing models yielded unsatisfactory results in our cohort. Almost one-third of the patients received PRT in the last 30 days of life. The use of hypofractionation for PRT was low in this Asian population. Further research is necessary to develop a predictive model of early mortality, allowing tailored end-of-life care for Asian patients.

Palliative radiotherapy is effective for both well- and poorly differentiated neuroendocrine neoplasms.

The outcomes of palliative radiation therapy (RT) for neuroendocrine neoplasms (NEN) are seldom reported. We investigated outcomes following palliative radiotherapy in a cohort of patients with NENs. We hypothesised that well-differentiated NEN will be less likely to have a clinical response than poorly differentiated NEN. Patients who received at least one course of palliative RT were identified using the New Zealand NETwork! Registry. Patients with Merkel cell carcinoma, pulmonary small cell carcinoma or asymptomatic patients were excluded. Clinical response to RT within 90 days and overall survival were analysed alongside clinical variables (fractionation, RT site, tumour differentiation and tumour primary site). The cohort comprised 79 patients, with 147 courses of palliative RT delivered. Clinical response was measurable for 100 courses, with clinical response rate of 76%. A course delivered to a well-differentiated NEN was associated with 2.02-fold (95% CI 0.67, 6.12; P = 0.21) increase in odds of a clinical response compared to a poorly differentiated NEN. Median overall survival from the first fraction of RT was 94 days (95% CI 80, 138 days). Overall survival was higher in well-differentiated NEN than in poorly differentiated NEN (HR 0.2, 95% CI 0.10-0.40, P-value < 0.001); 30-day mortality was 7%. There were significantly reduced odds of clinical response for non-bone sites, and for courses >10 fractions compared to a single fraction. Palliative RT is an appropriate option for management of symptoms in patients with both well- and poorly differentiated metastatic NEN.

Audit of 30-day mortality following palliative radiotherapy: are we able to improve patient care at the end of life?

Several measurements defining the expected 30-day mortality (30-DM) to use in audit of radiation oncology departments have been proposed. However, its external validity is limited because of the lack of data from non-English speaking countries. This study assessed 30-DM in patients treated with palliative radiotherapy (PRT) in a Chilean-reference radiotherapy centre and explored if there had been tailored treatment at the end of life. Retrospective data collection was carried out for all patients treated at our institution between 1st January 2018 and 31st December 2021. Individual factors were modelled first to check for univariate association with 30-DM, those variables with a significance level of < 0.05 were considered for the final multivariable model. 3,357 patients were included. The most common primary malignancies were breast (22%) and lung (16.1%). The most common treatment sites were bone (47.7%) and brain (12.2%). Overall, 30-DM was 14.7%, this rate was higher in patients treated for brain metastases (25.7%) and thoracic palliation (22.1%). 30-DM was associated with poor performance status (p < 0.01), lung and esophageal-gastric cancer (p = 0.04 and p = 0.02, respectively), metastases other than bone (p < 0.01), brain metastases (p < 0.01) and private health insurance (p <0.01). In patients treated for brain metastasis and thoracic palliation 30-DM was higher than suggested benchmarks. Moreover, in these groups long courses of PRT were often performed. Audit data should be useful for planning interventions that improve selection of patients and prompting review of policies for indication and fractionation schedules of PRT.

Comparison between 1-week and 2-week palliative radiotherapy courses for superior vena cava syndrome.

The aim of this study was to evaluate the effectiveness of palliative radiation therapy (RT) for superior vena cava (SVC) syndrome from lung cancer and to compare the 2-week and 1-week schedules. A retrospective study was conducted on lung cancer patients with palliative RT for SVC syndrome. Patients received 30 Gy in 10 fractions (2-week group) or 20 Gy in 5 fractions (1-week group) between July 2012 and June 2022. Treatment outcomes were evaluated at 1 to 2 months after RT. The tumor response and recanalization were evaluated based on the computed tomography (CT). Of the 39 patients, 24 received a 2-week course RT and 15 received a 1-week course of RT. The most common SVC-associated symptoms were edema (51.3%) and dyspnea (43.6%). There were no significant differences in performance status, histology, and grade of SVC. Symptom relief in symptomatic patients was comparable (85.7% in the 2-week group vs. 91.6% in the 1-week group; p = 0.581). There were no significant differences between the 2-week and 1-week groups in recanalization rates (62.5% vs. 60.0%; p = 0.876), tumor responses (75% vs. 60.0%; p = 0.876), and 6-month overall survival rates (29.2% vs. 36.4%; p = 0.726). In each of the two groups, one patient was consulted for re-irradiation. The median survival were 3.7 months for the 2-week group and 4.4 months for the 1-week group. In patients with SVC syndrome, the palliative effect of a 1-week course was equivalent to that of a 2-week course. Given the poor prognosis, a 1-week course may be an option.

Retrospective Review of Follow-up Strategies for Patients Receiving Palliative Radiotherapy.

There is no current standard-of-care follow-up strategy for patients who receive palliative radiotherapy (PRT) for bone metastases. Within our institution there is currently a heterogenous practice in which some providers schedule routine follow up 1-3 months after initial PRT while others do follow up only as needed (PRN). Our study aims to compare rates of retreatment based on follow-up strategies (planned vs. PRN), explore factors that potentially affect retreatment, and evaluate whether provider follow-up strategy correlates with measurable differences in quality of care. In a retrospective chart review, PRT courses for bone metastases at our single institution were divided by follow-up strategies (planned vs. PRN). Demographic, clinical, and PRT data were collected and analyzed via descriptive statistics. The relationship between planned follow-up appointment and subsequent retreatment was studied. More patients received retreatment within one year of initial PRT in the planned follow-up group than in the PRN follow-up group (40.4% vs. 14.4%, p<0.001). Retreatment was achieved sooner in the planned follow-up group than in the PRN follow-up group (137 days vs. 156 days). When accounting for other variables, having a planned follow-up appointment remains the most important factor in establishing retreatment (OR=3.32, 2.11-5.29, p<0.001). Having a planned follow-up appointment after the initial course of PRT improves identification of patients who would benefit from additional treatment, thus improving patient experience and quality of care.

Tolerability and response of palliative radiotherapy in patients receiving tumor-infiltrating lymphocyte therapy.

e14527 Background: Tumor-infiltrating lymphocyte (TIL) therapy is an emerging therapeutic option for patients with metastatic tumors having progressed on multiple lines of systemic therapy. It is unknown how TIL therapy impacts the tolerability and effectiveness of palliative radiotherapy (RT). We herein present a case series of patients having received both TIL therapy and palliative RT along with the associated local responses and toxicity profiles. Methods: A single institution retrospective database review identified patients treated with TIL therapy following progression on ≥2 standard treatment(s) for metastatic disease. Patients were eligible for inclusion if they received palliative radiotherapy treatment within 1 year of TIL delivery as pre- or post-TIL therapy. Patient demographic data was collected and descriptive statistics reported. Radiographic imaging response was assigned in accordance with Response Evaluation Criteria in Solid Tumors (RECIST). Toxicities were graded in accordance with Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. Results: Between 2017–2021, a total of 10 patients receiving TIL therapy treated across 12 courses of palliative RT were included for analysis. 8 of 10 patients (80%) had a primary diagnosis of malignant melanoma and 2 (20%) had non-small cell lung cancer. RT was administered to 7 patients pre- and 3 patients post-TIL therapy. Within the pre-TIL cohort, 2 patients received RT between TIL harvest and infusion. Patients received an average total dose of 26 Gy (range, 8-45 Gy). Median patient follow-up after RT was 6 months. Of the patients who received RT prior to TIL therapy, 6 of 9 sites demonstrated at-least stable disease at the site of RT versus 1 of 3 sites receiving post-TIL RT. Across the cohort, 2 patients experienced Grade 1 toxicities associated with RT treatment. No Grade 2+ events were reported. Conclusions: Palliative RT appears to be safe and tolerable when delivered both prior to and post-TIL therapy. RT may be an option for bridging therapy between TIL harvest and infusion. Local response rates to RT were greater in patients receiving RT prior to TIL infusion. Further investigations are warranted to determine the optimal dose, fractionation, and timing of RT when integrating it into future TIL therapy protocols. [Table: see text]

Percent of remaining life on palliative radiation treatment: solely a function of fractionation?

This study analyzed the percent of remaining life (PRL) on treatment in patients irradiated for bone metastases. Bone metastases were treated together with other target volumes, if indicated, e.g. a 10-fraction treatment course that included brain and bone metastases. PRL was determined by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. Different baseline parameters were assessed for association with dichotomized PRL (< 5% vs. ≥ 5%). The retrospective study included 219 patients (287 courses of palliative radiotherapy). After univariate analyses, multi-nominal logistic regression was employed. PRL on treatment ranged from 1-23%. Single-fraction radiotherapy resulted in < 5% PRL on treatment in all cases. All courses with 10 fractions resulted in at least 5% PRL on treatment. Significant associations were found between various baseline parameters and PRL category. With fractionation included in the regression model, 3 parameters retained significant p-values: Karnofsky performance status (KPS), none-bone target volume and fractionation (all with p < 0.001). If analyzed without fractionation, none-bone target volume (p < 0.001), hemoglobin (p < 0.001), KPS (p = 0.01), lack of additional systemic treatment (p = 0.01), and hypercalcemia (p = 0.04) were significant. Fractionation is an easily modifiable factor with high impact on PRL. Patients with KPS < 70 and those treated for additional target types during the same course are at high risk of spending a larger proportion of their remaining life on treatment.

Palliative appropriateness criteria: external validation of a new method to evaluate the suitability of palliative radiotherapy fractionation

BackgroundRecently, the palliative appropriateness criteria (PAC) score, a novel metric to aid clinical decision-making between different palliative radiotherapy fractionation regimens, has been developed. It includes baseline parameters including but not limited to performance status. The researchers behind the PAC score analyzed the percent of remaining life (PRL) on treatment. The latter was accomplished by calculating the time between start and finish of palliative radiotherapy (minimum 1 day in case of a single-fraction regimen) and dividing it by overall survival in days from start of radiotherapy. The purpose of the present study was to validate this novel metric.Patients and methodsThe retrospective validation study included 219 patients (287 courses of palliative radiotherapy). The methods were identical to those employed in the score development study. The score was calculated by assigning 1 point each to several factors identified in the original study and using the online calculator provided by the PAC developers.ResultsMedian survival was 6 months and death within 30 days from start of radiotherapy was recorded in 13% of courses. PRL on treatment ranged from 1 to 23%, median 8%. Significant associations were confirmed between online-calculated PAC score, observed survival, and risk of death within 30 days from the start of radiotherapy. Patients with score 0 had distinctly better survival than all other groups. The score-predicted median risk of death within 30 days from start of radiotherapy was 22% in our cohort. A statistically significant correlation was found between predicted and observed risk (p < 0.001). The original and present study were not perfectly concordant regarding number and type of baseline parameters that should be included when calculating the PAC score.ConclusionThis study supports the dual strategy of PRL and risk of early death calculation, with results stratified for fractionation regimen, in line with the original PAC score study. When considering multifraction regimens, the PAC score identifies patients who may benefit from shorter courses. Additional work is needed to answer open questions surrounding the underlying components of the score, because the original and validation study were only partially aligned.

Intramedullary spinal cord metastases from non-small cell lung carcinoma (NSCLC) associated with carcinomatous meningitis: a case report

Abstract Background: Carcinomatous meningitis with metastases to the spinal cord [intramedullary spinal cord (IMSC)] is very rare, and a quick intervention to management of these patients is important in preventing neurological deterioration. Methods: We report a case of IMSC metastases from a stage IV non-small cell lung carcinoma in a 57-year-old man who presented with Brown-Sequard syndrome along with multiple brain metastases with associated carcinomatous meningitis and managed with urgent palliative external beam radiation therapy. Conclusion: A quick, short course of palliative radiation therapy for inoperable patients with IMSC metastases provides improvement in neurological function in the management of these oncologic emergencies in patients with short survival times.

Prognostic Understanding and Goals of Palliative Radiotherapy: A Qualitative Study.

There is a paucity of data describing patients' expectations of goals of palliative radiotherapy (RT) and overall prognosis. To explore patients' perceptions of and preferences for communication surrounding goals of palliative RT and cancer prognosis. We conducted a qualitative study utilizing semi-structured interviews with seventeen patients with either bone or lung metastases receiving their first course of palliative RT at a comprehensive cancer center. All patient interviews were recorded, transcribed verbatim, and thematically analyzed. Themes of goals of palliative RT centered on either restoration, such as through improving quality of life or minimizing pain, or on a desire to combat cancer by eliminating tumor. While most patients perceived that palliative RT would palliate symptoms but not cure their cancer, some patients believed that the goal of palliative RT was to cure. Themes that emerged surrounding patients' understanding of prognosis and what lies ahead included uncertainty and apprehension about the future, a focus on additional treatment, and confronting mortality. Most patients preferred to receive information about goals of treatment and prognosis from their doctors, including radiation oncologists, rather than other members of the medical team. Patients also expressed a desire for written patient education materials on palliative RT. Unclear perceptions of goals of treatment and prognosis may motivate some patients to pursue unnecessarily aggressive cancer treatments. Patients desire prognostic information from their doctors, including radiation oncologists, who are important contributors to goals of care discussions and may improve patient understanding and well-being by using restorative rather than combat-oriented language.

Pediatric Radiotherapy Utilization rate (PUR) in a large pediatric oncology center in Low-/Middle-Income country (LIMC): Report on 14473 patients

<h3>Objectives</h3> To determine the real-life radiotherapy utilization rate in pediatric cancer patients in a large pediatric cancer institution. Although RUR is specified for most adult cancers, it is seldom reported in childhood tumors. <h3>Methods</h3> A real-life RUR for pediatric tumors was performed in a large low-/middle-income country (LMIC) center from 2009 to 2017 in 2 studies. The RUR was defined as the percentage of patients who received at least one radiotherapy (RT) course from the total number of patients. <h3>Results</h3> The first study included 4390 out of 13,305 pediatric cancer patients with a RUR of 33%. The curative, salvage and palliative RURs were 27.8%, 2%, and 5.7%, respectively. There was a considerable variation in the RUR between various tumors, ranging from 0% in choroid plexus papilloma and other rare tumors to 100% in intracranial germinoma. The second study compared RUR in 2 subsequent periods, 2009-2013 and 2014-2017. RUR was estimated as 32.5% (4707/14473). There was no statistically significant difference for RUR in the two time periods (32.9% versus 32.3%). However, Hodgkin's lymphoma, neuroblastoma, soft tissue sarcoma (rhabdomyosarcoma and non-rhabdo-), and renal tumors RUR increased significantly in 2014 2017 compared to 2009 – 2013. On the contrary, brain tumors, bone tumors, retinoblastoma, and rare pediatric tumors RUR decreased significantly in the same period. Moreover, the RUR varied among different stages within each tumor type. Moreover, 753 patients received 920 palliative RT courses (range 1–9) at a median dose of 30 Gy. <h3>Conclusion</h3> Upon applying the same treatment protocols, different RUR were reported in various tumor types and different periods. The most commonly irradiated metastatic sites were the bone (34%) and the brain (9.8%). However, still, there is underutilization of palliative RT that calls for more efficient multidisciplinary palliative care provision for pediatric cancer patients.

О ЦЕЛЕСООБРАЗНОСТИ ПРОВЕДЕНИЯ ПОВТОРНОЙ РАДИОТЕРАПИИ ПРИ РЕЦИДИВАХ И ПРОДОЛЖЕННОМ РОСТЕ РАНЕЕ ОБЛУЧЕННЫХ ОПУХОЛЕЙ РАЗЛИЧНОЙ ЛОКАЛИЗАЦИИ

Introduction: The development of a recurrence or a second tumor in previously irradiated patients requires, in some cases, repeated radiotherapy (reirradiation) of the previously irradiated tissue volume. In the past decades, it was widely believed that it was possible to irradiate one anatomical zone in curative doses only once (taking into account the tolerance of healthy tissues) and the issue of repeated irradiation was practically not discussed (there are only a few studies). This approach was due to the fact that the use of old technologies did not allow sufficient protection of healthy tissues surrounding the tumor, which led to severe complications. Due to the development of radiotherapy technologies and new advances in radiobiology, the number of studies on the re-irradiation of recurrent tumors has recently increased significantly, however, they are mainly retrospective in nature and do not have a sufficient evidence compared to indications for primary radiotherapy. However, reirradiation can be used not only for palliative purposes, but also to achieve long-term local control. Modern medical approaches and technical capabilities make it possible to re-irradiate tumors of any localization, up to the second curative dose. Purpose: To investigate the expediency of repeated irradiation of patients with different tumor localizations, taking into account the survival rates of patients, possible complications and subsequent quality of life. Materials and methods: For the first time in Armenia, an analysis of the results of reirradiation is carried out on the basis of the experience of one clinic. The results of treatment of 1300 patients, who received radiotherapy at the IRA MEDICAL Group Radiotherapy Center from March 2019 to March 2022 were studied. The study included 52 patients, who received the second course of RT, which accounted for 4% of the total number of patients. The median age of patients was 60.5 years (22 - 81), including 22 men, 30 women, based on pathologies: CNS tumors - 17 patients, brain metastasis - 10, gynecology - 6, head and neck tumors - 6, metastatic skeletal bone lesions - 4, breast cancer - 3, other localizations - 6. Stage of the disease: III - 7 patients, IV - 37, unclassified - 8. The mean interval between two courses of radiotherapy was 34.5 months (1.5 - 252). The median total equivalent dose from two irradiation courses is 99 Gy (56-121). Except of the patients, who received reirradiation for metastatic relapse, the total equivalent dose was 102 Gy (84–121), and the median follow-up time after reirradiation was 9 months (4–29.5). Results: The average life expectancy of patients, who died during the observation period was 6.5 months (1-23). In 7 out of 52 patients, who initially had low KPS (60%), survival was up to 3.5 months or less. After excluding these patients from further statistical analysis, the median survival of the remaining patients was 10 months (4 – 23). As of March 31, 2022, 31 patients (59.6%) are alive, with an average follow-up of 13 months (5 – 29.5). The number of post-radiation complications and the quality of life of patients were also assessed. There were no treatment related deaths or reduced quality of life in the early stages. The results of this prospective study demonstrate that the use of the latest technologies in repeat radiotherapy can improve survival and quality of life in these patients. Thanks to new technologies, it is possible to conduct a repeated course of radiotherapy even in curative doses. When planning the second therapeutic or palliative course of radiotherapy, it is necessary to carefully select patients, taking into account a number of factors related to the previous treatment and the individual characteristics of the patient. After completion of the study, we plan to create recommendations on the criteria for selecting candidates for re-irradiation.

Natural Language Processing of Symptoms Preceding Diagnosis and Palliative Radiotherapy for Bone Metastases

<h3>Purpose/Objective(s)</h3> In patients with bone metastases (BM), the goal of palliative radiotherapy (RT) is to ameliorate pain and other symptoms. We sought to apply natural language processing (NLP) techniques to routine clinical documentation to characterize symptoms associated with diagnosis of BM and initiation of palliative RT. We hypothesized that there may be disparities in symptom presentation for patients with BM receiving palliative RT. <h3>Materials/Methods</h3> We used International Classification of Diseases (ICD) codes along with Current Procedural Terminology (CPT) codes to create a de-identified, single tertiary-care institution cohort of patients with BM who received palliative external beam RT or stereotactic body RT between 2013 and 2021. Clinical data, clinical notes, and meta-data on clinical notes for the patient cohort were computationally extracted from an institutional electronic health record repository. We applied a previously validated clinical Text Analysis and Knowledge Extraction System (cTAKES) pipeline to extract Common Terminology Criteria for Adverse Events (CTCAE) encoded symptoms from all notes in the 30 days preceding BM diagnosis and in the 30 days preceding each course of palliative RT. Chi-squared tests were used to compare symptom distributions across groups. <h3>Results</h3> There were 1,021 patients who received 1,551 courses of palliative RT for BM. Median age at BM diagnosis was 63 years (IQR: 54-71). Median time from BM diagnosis to first course of palliative RT for BM was 2.3 months (IQR: 0.7-14.9). Most patients were male (57.5%), English-speaking (86.2%), and white (59.2%). The most common symptoms prior to BM diagnosis were pain (75.6%), nausea (44.9%), fatigue (41.6%), and palpation of a mass (38.4%). Across RT courses, the most common symptoms prior to palliative RT were pain (90.4%), nausea (67.9%), fatigue (67.6%), and constipation (54.2%). On subgroup analysis of symptoms prior to RT, there were increased NLP-derived reports of pain in clinical notes among patients who were female (94.9% vs male: 87.0%, p < 0.001), non-white (93.3% vs white: 88.8%, p = 0.007), and non-English speaking (97.0% vs English: 89.5%, p = 0.002). Compared to their respective counterparts, female (33.2% vs male: 24.6%, p < 0.001) and non-English speaking patients (36.5% vs English: 27.2%, p = 0.012) were more likely to have experienced pathologic fractures prior to RT. <h3>Conclusion</h3> Patients who were women, non-white, or non-English speaking were documented to have higher rates of pain and/or pathologic fracture prior to palliative RT. These findings may reflect disparities in patient presentation, clinical documentation, or decision-making for which patients are offered palliative RT sooner in the disease trajectory. Future research coupling NLP techniques with machine learning may be useful for predicting which patients would benefit most from earlier initiation of palliative RT.

Retrospective Review of Follow-Up Strategies for Patients Receiving Palliative Radiotherapy

<h3>Purpose/Objective(s)</h3> There is no current standard-of-care follow-up strategy for patients who receive palliative radiotherapy (PRT) for bone metastases. Within our institution some providers schedule routine follow-up appointments while others only have follow-up as needed (PRN) following a course of PRT. Our study aims to evaluate whether provider follow up strategy correlates with measurable differences in overall quality of care (QoC). We hypothesize that having a routine follow-up appointment following a course of PRT correlates with improved QoC through improved identification of patients who would benefit from additional treatment. <h3>Materials/Methods</h3> Through retrospective chart review, we identified patients who received PRT for bone metastases at our single institution. Inclusion criteria consisted of age ≥ 18 years at the time of treatment and initial PRT course between July 2020 and June 2021. Patients with bone metastases were identified by ICD-10 codes, radiation course name, and PRT dose. Brain and other non-bone metastases were excluded. Demographic, clinical, and PRT data, and time to retreatment were collected and analyzed via descriptive statistics. Follow-up strategies for PRT patients were identified among 17 radiation oncologists. Differences in rate of retreatment were assessed via Fishers exact test. <h3>Results</h3> A total of 378 unique PRT courses were included in our study. PRT courses were divided into separate cohorts based on having scheduled follow-up post treatment (n=160, 42.3%) vs PRN follow up (n=218, 57.7%). The average patient was 64 years old at the time of treatment in both groups. The most common malignancies were breast (n=80, 21%), prostate (n=78, 20.6%), and lung (n=41, 10.8%) with similar proportions in each group. 191 (50.5%) courses included spinal metastases and 187 (49.5%) included non-spine bone metastases with no significant differences between cohorts. Among the scheduled follow-up cohort, more patients (n=65, 40%) received additional treatment within the following year as either retreatment of the initial site or treatment of new sites of pain when compared to the PRN follow up cohort (n=38, 17%). Patients with scheduled follow up had a shorter median time to retreatment of 103 days vs 142 days in the PRN follow up group. <h3>Conclusion</h3> In our retrospective study, we found that having at least one routine follow up for patients receiving PRT led to higher rates of additional treatment with PRT (40% vs 17%, p<0.01) and a shorter median time to retreatment (103 days vs 142 days). Our study shows potential improvement in the QoC for patients receiving PRT through better identification of patients in need of additional PRT. We acknowledge several limitations to this retrospective analysis including primarily the risk of selection bias which we intend to further explore on subsequent analysis. Our results may serve as a clinical basis to suggest a routine 1–3 month follow up after a course of PRT for bone metastases.

Hypofractionated Palliative Radiotherapy for Relapsed and Refractory High-Risk Neuroblastoma

<h3>Purpose/Objective(s)</h3> While palliative radiation therapy (RT) is frequently used in the management of relapsed/refractory high-risk neuroblastoma (HR-NBL) in pediatric patients, few studies have examined the role of palliative hypofractionated RT (hypo-RT) in HR-NBL. We sought to characterize outcomes after palliative-intent RT using conventionally fractionated (conv-RT) and hypo-RT regimens for patients with relapsed/refractory HR-NBL. <h3>Materials/Methods</h3> The Institutional Review Board approved a retrospective study of 37 patients who were diagnosed with HR-NBL between 1997-2021 and received palliative RT at two institutions. Patients receiving RT for central nervous system and liver metastases were excluded. Hypo-RT was defined as treatment courses using dose >2 Gy per fraction. Clinical and treatment characteristics and outcomes, including dates and locations of progression, were recorded. Fisher exact tests were used for categorical variables. Follow-up time was defined from start of RT. Cumulative incidence of in-field progression was analyzed using Gray's test with death as competing risk. Univariate analyses (UVA) were performed using Cox proportional-hazards regression. <h3>Results</h3> When analyzing by first course of palliative RT, there were 16 courses of conv-RT (43.2%) and 21 courses of hypo-RT (56.8%). The distribution of patients having further progression of disease before palliative RT, receiving palliative RT to bony and soft tissue sites, and undergoing chemotherapy before, during, and after palliative RT were not different between the two groups. With median follow-up of 10.3 months (range: 0.3-104.0), cumulative incidence of in-field progression at 10 months was not different between hypo-RT and conv-RT (30.0% vs 20.1%, p=0.80). After RT, patients had similar clinical benefit, defined as symptomatic relief or decrease in size of lesion (92.3% conv-RT vs. 90.0% hypo-RT, p=1.00). On UVA, further progression of disease before palliative RT, bony vs. soft tissue sites, receipt of chemotherapy before RT, receipt of concurrent chemotherapy with RT, and receipt of chemotherapy after RT were not associated with time to in-field progression. In addition, hypo-RT (Hazard ratio [HR]: 1.50, 95% confidence interval [CI]: 0.47-4.76, p=0.49) and biologically equivalent dose (BED) ≥29 Gy (HR: 1.44, 95% CI: 0.43-4.82, p=0.55) were not associated with time to in-field progression. <h3>Conclusion</h3> We found no difference in cumulative incidence of in-field progression and clinical outcomes between the conv-RT and hypo-RT groups. On UVA, hypo-RT and BED ≥29 Gy were not associated with longer time to in-field recurrence. Palliative hypo-RT can be considered for relapsed/refractory HR-NBL, especially when quality of life from shorter treatments may be of benefit.

Palliative Appropriateness Criteria: A Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation.

Purpose: To describe a novel metric to aid clinical decision making between shorter versus longer palliative radiotherapy (PRT) regimens using objective patient factors. Materials and Methods: Patients receiving PRT at a single institution between 2014 and 2018 were reviewed. The time between PRT start and finish was calculated and divided by overall survival (in days from start of PRT) to generate the percent of remaining life (PRL). This value was compared across various clinical factors using the Kruskal-Wallis test. Factors identified with a significance level p < 0.01 were included in a novel Palliative Appropriateness Criteria Score (PACS) and were included in an online risk assessment tool to assist clinicians in patient-specific fractionation decisions. Results: Totally 1027 courses of PRT were analyzed. Median age was 64 years; Eastern Cooperative Oncology Group (ECOG) performance status was 3-4 in 22%. Primary malignancies included were lung (38%), breast (13.8%), prostate (9.3%), and other (39%). The indication for PRT was pain (61%), neurological (21%), or other (18%). Palliative regimens included 199 (19.4%) receiving single fraction, 176 (17.1%) receiving 2-5 fractions, and 652 (63.5%) receiving 10 fractions. Median follow-up was 83 days overall and 437 days for patients alive at last follow-up. Factors significantly associated with increased PRL (and included in the PACS) were male gender, ECOG 3-4, lung or "other" primary diagnosis (vs. breast or prostate), PRT indication (neurological dysfunction vs. pain/other), inpatient status, and extraosseous sites treatment. Death within 30 days was significantly associated with high-risk PACS categorization, regardless of fractionation scheme (p < 0.001). Conclusions: The PACS is a novel metric for evaluating the utility of PRT regimens to improve clinical decision making. Single fraction is associated with low PRL. When considering multifraction PRT regimens, the PACS identifies patients who may benefit from shorter courses of PRT and alternatively, low-risk patients for whom a more protracted course is reasonable. Prospective external validation is warranted.

Palliative radiotherapy for gastric cancer bleeding: a multi-institutional retrospective study

BackgroundPalliative radiotherapy for gastric cancer bleeding has been reported to be a safe and effective treatment, but predictive factors for achievement of hemostasis and overall survival have not been established.MethodsIn this retrospective study, 120 courses of palliative radiotherapy for gastric cancer bleeding in 117 patients in 4 institutes in Japan were reviewed with approval of the ethical committee in each institute. The rate of achieving hemostasis was evaluated by 50% or more reduction of red blood cell transfusion before and after the start of radiotherapy, elevation of blood hemoglobin concentration in a period of 4 weeks from the start of radiotherapy or improvement of subjective or objective clinical symptoms in a period of 4 weeks from the start of radiotherapy. Predictive factors for overall survival and achieving hemostasis were investigated with the Cox hazards model.ResultsThe median overall survival period was 3.7 months. Multivariate analysis showed that absence of metastatic disease, higher biological effective dose, higher serum albumin level, lower blood urea nitrogen level and lower neutrophil-to-lymphocyte ratio (NLR) were associated with longer overall survival. Elevation of hemoglobin concentration in a period of 4 weeks from the start of radiotherapy (mean concentration: 8.2 g/dL vs. 8.9 g/dL, p = 0.006) and decrease in the amount of red cell transfusion from a 4-week period before to a 4-week period after the start of radiotherapy (mean amount: 716 mL vs. 230 mL, p < 0.0001) were observed. The overall rate of achievement of hemostasis was 59.6%. In multivariate analysis, higher biological effective dose was associated with achievement of hemostasis. Grade 2 or higher acute adverse effects related to radiotherapy were observed in 17.5% of cases in 120 treatment courses. Six cases (5.0%) had grade 3 or 4 adverse effects including gastric penetration in 1 patient and anorexia requiring total parental nutrition in 3 patients. No grade 5 adverse effects were observed.ConclusionsPalliative radiotherapy for gastric cancer bleeding seems to be an effective and safe treatment strategy. Higher treatment dose was associated with longer overall survival and a hemostatic effect. Some hematological parameters may predict overall survival, and they would be helpful for deciding the treatment strategy.

Dual Use of the METSSS Model Predicting Survival After Palliative Radiotherapy: An Exploratory Analysis.

Introduction: The recently published METSSS model, which was developed for prediction of survival after palliative radiotherapy, includes age, sex, cancer type, localization of distant metastases, Charlson-Deyo comorbidity score and radiotherapy site. Its ability to predict other relevant endpoints has not been studied yet. Therefore, this exploratory study analyzed the endpoints “unplanned termination of radiotherapy” and “treatment in the last 30 days of life” in the METSSS-defined risk groups (low/medium/high).Methods: The risk group was assigned in the METSSS online calculator for our patient cohort with non-hematological malignancies treated between 2009 and 2014 during the first course of treatment (resembling details of the original METSSS study). All patients were treated with classical palliative dose/fractionation regimes such as five fractions of 4 Gy, 10 fractions of 3 Gy or 13 fractions of 3 Gy. No stereotactic high-dose radiation was utilized. Given that single-fraction radiotherapy cannot be discontinued, patients treated with 8 Gy x1 for uncomplicated painful bone metastases were excluded. Both completed and discontinued multi-fraction radiotherapy courses (at least two fractions intended) were included.Results: The study included 290 patients, 19 of whom failed to complete their prescribed course of palliative radiotherapy (7%). Thirty-nine (13%) were irradiated in the last 30 days of life. Only one patient was classified as low-risk according to the METSSS model (medium: 15, high: 274). Only Eastern Cooperative Oncology Group (ECOG) performance status (PS) was significantly associated with incomplete treatment. All 16 patients with low/medium METSSS risk scores completed their prescribed course of radiotherapy, compared to the 93% completion rate in the high-risk group, p=0.41. With regard to treatment in the last 30 days of life, ECOG PS, metastases to brain, liver and lung, and the number of prescribed fractions were statistically significant. One patient with a low/medium METSSS risk score was treated in the last 30 days of life (6%), compared to 14% in the high-risk group, p=0.49.Conclusion: Unexpected imbalances in the METSSS risk group size resulted in lower statistical power than anticipated. Patients with low/medium METSSS risk scores performed numerically better. However, other predictive factors, especially ECOG PS, which is not part of the METSSS model, maybe more relevant. Further efforts towards the application of the model beyond its original objective cannot be recommended.

Clinical Outcomes of Patients Treated with Short-course Palliative Radiotherapy in the First Year of the COVID-19 Pandemic: A Single Institution Experience

Objective. This study aimed to describe the clinical profile and treatment outcomes of patients treated with a short course (&lt;10 fractions) of palliative radiotherapy during the first year of the COVID-19 pandemic. Another aim of the study is to compare patients treated with short-course and long-course palliative radiotherapy in terms of the site and volume irradiated. Methods. An ambispective study comprised 23 patients treated with short-course palliative radiotherapy from March 2020 to February 2021. The retrospective aspect of this study included a review of medical records and radiotherapy plans, while the prospective part involved communication with patients or legally authorized representatives via phone call. Demographic, clinical, and treatment-related information were gathered. Results. Of 92 patients receiving palliative radiotherapy, 23 were treated with a short course, while 69 were planned for at least ten fractions. Of the 23 patients receiving short-course radiotherapy, most had colorectal (35%) and head and neck (26%) primary malignancies. The most commonly treated sites were the pelvis (24%), vertebral bones (21%), and head and neck masses (21%), and the most common indications were pain (45%) and bleeding (32%). The majority were treated with 20 Gy in 5 fractions (42%) and 25 Gy in 5 fractions (38%). Complete resolution of symptoms was observed in 43% of cases, and more than half reported no side effects (58%). Median survival was 71 days. All patients treated in the lung, stomach, and brain underwent a long course of palliative radiotherapy. Patients with a long course also had higher mean irradiated volumes (1871 cm3 vs. 2150 cm3). Conclusion. In this single institution review, a short course of palliative radiotherapy was proven to provide good symptom control with few side effects. During the COVID-19 pandemic, its use should be strongly considered, especially in patients with poor performance status, transportation difficulties, and limited life expectancy.