Radiation Therapy Cohort Research Articles

Omission of adjuvant radiotherapy in low-risk elderly males with breast cancer

PurposeRandomized clinical trials demonstrate that lumpectomy + hormone therapy (HT) without radiation therapy (RT) yields equivalent survival and acceptable local–regional outcomes in elderly women with early-stage, node-negative, hormone-receptor positive (HR +) breast cancer. Whether these data apply to men with the same inclusion criteria remains unknown.MethodsThe National Cancer Database was queried for male patients ≥ 65 years with pathologic T1-2N0 (≤ 3 cm) HR + breast cancer treated with breast-conserving surgery with negative margins from 2004 to 2019. Adjuvant treatment was classified as HT alone, RT alone, or HT + RT. Male patients were matched with female patients for OS comparison. Survival analysis was performed using Cox regression and Kaplan − Meier method. Inverse probability of treatment weighting (IPTW) was applied to adjust for confounding.ResultsA total of 523 patients met the inclusion criteria, with 24.4% receiving HT, 16.3% receiving RT, and 59.2% receiving HT + RT. The median follow-up was 6.9 years (IQR: 5.0–9.4 years). IPTW-adjusted 5-yr OS rates in the HT, RT, and HT + RT cohorts were 84.0% (95% CI 77.1–91.5%), 81.1% (95% CI 71.1–92.5%), and 93.0% (95% CI 90.0–96.2%), respectively. On IPTW-adjusted MVA, relative to HT, receipt of HT + RT was associated with improvements in OS (HR: 0.641; p = 0.042). RT alone was not associated with improved OS (HR: 1.264; p = 0.420).ConclusionAmong men ≥ 65 years old with T1-2N0 HR + breast cancer, RT alone did not confer an OS benefit over HT alone. Combination of RT + HT demonstrated significant improvements in OS. De-escalation of treatment through omission of either RT or HT at this point should be done with caution.

(161) Is there a Difference in Inflatable Penile Prosthesis Mechanical Failure and Infections Rates in Relation to Prostate Cancer Treatment Modality (Radiation Therapy vs Radical Prostatectomy)

Abstract Introduction Inflatable Penile Prosthesis (IPP) implantation as a treatment for ED has high satisfaction rates in the general population; however, there is limited literature on quantification of complication rates as stratified by ED etiology. Objective Our aim was to compare mechanical failure and infection rates in patients undergoing IPP implantation for ED following Radical Prostatectomy (RP) versus radiation therapy (RT) for prostate cancer. Methods A retrospective chart review from our institutional database was conducted to identify 405 patients who underwent IPP placement at our institution from 2015–2019, then selecting for those whose etiology of ED was following RP or RT. To prevent crossover confounding; patients with history of pelvic radiation or salvage radiotherapy were excluded from the RP group and patients with history of RP were excluded from the RT group. Data was obtained from 75 patients who met criteria for inclusion: 44 patients in the RP group and 31 patients in the RT group. Mechanical failure, infection rates, mean EDITS scores and additional survey questions were compared between the radiation and RP groups. Results Patient demographic information and IPP complication and satisfaction rates are listed below in Table 1 and Figure 1. There was a statistically significant difference in number of patients experiencing IPP complications, 19.4% (n=6) of patients in the RT cohort and 4.5% (n=2) in the RP cohort, respectively. There was no statistically significant difference found in stratified complications- infection rates, device erosion rates, mechanical failure rates, or device removal and/or replacement rates between the two groups. The RP cohort had a significantly higher mean Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire score versus the RT cohort, 91.58 to 76.02, respectively. Conclusions These preliminary findings, while requiring large-scale follow up, suggest that there is a higher rate of IPP related complications in patients with device placement following RT for prostate cancer versus RP. Disclosure No.

The Importance of Timing of Physical Therapy in Relation to Radiation Therapy during Multimodality Breast Cancer Treatment to Maximize Shoulder Range of Motion

Physical therapy (PT) is an effective tool for improving range of motion (ROM) for breast cancer patients to reduce long-term impairment. There is a paucity of data surrounding when PT should be initiated to optimally reduce upper limb disability. We hypothesized that patients who initiated PT early after surgery and before radiation therapy (RT), would experience greater gains in functionality compared to PT during/after RT. Demographic/clinical variables were assessed via retrospective chart review for patients referred to outpatient PT and receiving multimodality treatment for breast cancer between January 2015 and August 2021. Three distinct cohorts were established: patients who received PT and no RT, PT initiated before radiation therapy (pre-RT), and PT initiated during/after RT (d/a RT). The primary endpoint was percent change of total ROM of the ipsilateral shoulder between the first and last PT visits. Secondary endpoints included absolute change in degrees of total ROM of the ipsilateral shoulder between first and last PT visits. Associations between ROM across PT groups and baseline characteristics were evaluated with analysis of variance (ANOVA) testing. Thirty-seven patients were identified, median age 47 years (range 28-76). Higher tumor stage and axillary lymph node dissection were associated with the receipt of RT (p = 0.023, p = 0.003 respectively). Baseline ROM was associated with both percent and absolute improvement in ROM (p = 0.007). Patients receiving no RT demonstrated the greatest mean percent improvement in ROM with PT (84%), compared to the pre-RT and d/a RT cohorts, which demonstrated a 63% and 40% improvement, respectively. In pairwise comparisons, patients in the no RT group and those in the PT pre-RT group both demonstrated a statistically greater improvement in percent change in ROM compared to patients receiving PT d/a RT (no RT 74% vs d/a RT 20%, p = 0.006; pre-RT 59% vs d/a RT 20%, p = 0.045). There was no difference in percent change in ROM between the no RT and pre-RT groups (p = 0.528). On univariate analysis, baseline worse ROM was associated with statistically worse percent change in ROM after PT (p = 0.008), no other baseline characteristics were associated with ROM after PT. When adjusting for baseline ROM, the no RT cohort continued to be associated with improvement in ROM compared to the PT d/a RT group (p = 0.024), while there was no difference in percent change in ROM between patients who received physical therapy pre-RT compared to no RT (p = 0.829). Physical therapy is helpful in improving shoulder ROM at all stages of multimodality breast cancer treatment, however early initiation of PT prior to the start of RT may help maximize range of motion gains.

Outcomes Following Radiation Therapy (RT) for Very Young Age CNS Embryonal Tumors on COG ACNS0334 According to Molecular-Confirmed Diagnosis

The outcomes of upfront or relapse radiation therapy (RT) for the Children's Oncology Group ACNS0334 protocol based on molecular diagnosis were assessed. Therapy included maximal safe surgery, high-dose chemotherapy with stem cell rescue, randomization for inclusion of high dose methotrexate (MTX) and optional RT. There were 24 patients that received RT on COG ACNS0334 of 77 evaluable patients with a diagnosis of either high-risk medulloblastoma (MB) or supratentorial primitive neuroectodermal tumor (SPNET). RT was a recommendation (M0: Focal, M+: CSI 18 Gy) given young patient age <36 months at enrollment. Seven RT patients were excluded for ineligible pathology (1 ATRT, 1 HGG) or insufficient tissue. The aim of this report is to review outcomes of 17 patients on ACNS0334 receiving RT (8 Upfront, 9 at relapse) with a molecular diagnosis that included MB, Pineoblastoma (PB), or Embryonal tumor with multilayered rosettes (ETMR). In the MB group, there were 9 patients irradiated with MB (Group 3 = 8, SHH = 1). 5-year OS for MB Group 3 receiving RT (median primary dose 54 Gy) was 62.5% with no difference observed comparing 6 patients treated with upfront RT versus 2 treated at relapse (p = 0.27). All upfront RT for MB Group 3 had initial partial response (PR) to 0334 chemotherapy. RT delivery for upfront RT MB Group 3 included craniospinal radiation (CSI) in 5 patients and 1 patient who received focal RT to the primary (50 Gy) and metastatic site (44 Gy). Eighty percent of CSI for upfront RT in Group 3 was 18 Gy or 23.4 Gy. Relapse RT for MB Group 3 (2 patients) utilized full dose CSI (36 Gy, 39.6 Gy) and both patients are survivors with 5+ years follow-up. CSI dose for Group 3 MB was higher for relapse RT (mean 37.8 Gy) as compared to upfront RT (mean 19.8 Gy, p = 0.013). Use of MTX was 50% in both upfront RT and relapse RT Group 3 MB cohorts. One patient with MB SHH (classic histology) underwent upfront focal RT (54 Gy) after initial PR to systemic therapy (without MTX) and is surviving 5+ years. PB: Of 4 PB patients (median primary dose 48.8 Gy) 1 had RT upfront (CSI 18 Gy) and 3 had RT at relapse (1 patient received CSI, 21 Gy). All patients with PB expired within 2 years. MTX was given in 75% (including 1 upfront RT PB). Two of 3 patients treated at relapse had prior complete response (CR). ETMR: All 4 patients (median primary dose 54 Gy) with ETMR were treated at relapse, with CSI given in 1 patient (23.4 Gy). All patients with ETMR expired within 2 years, and 2 (50%) had received MTX. Two patients (50%) had initial CR. The RT cohort for Group 3 MB on ACNS0334 exhibited long-term survival both for both upfront and relapse RT, however relapsed Group 3 MB received higher dose CSI. RT upfront for MB, including one surviving MB SHH patient receiving focal RT, was solely given for incomplete initial chemotherapy response. There were no survivors for either PB or ETMR when the majority (88%) were treated at relapse.

Predicting 18F-DCFPyL-PET/CT Scan Positivity in Prostate Cancer Patients with Biochemical Recurrence

To analyze variables that can predict the positivity of 18F-DCFPyL- positron emission tomography/computed tomography (PET/CT) and extent of disease in patients with biochemically recurrent (BCR) prostate cancer after primary local therapy with either radical prostatectomy or radiation therapy. This is a retrospective analysis of a prospective single institutional review board-approved study. We included 199 patients with biochemical recurrence and negative conventional imaging after primary local therapies (radical prostatectomy n=127, radiation therapy n=72). All patients underwent 18F-DCFPyL-PET/CT. Univariate and multivariate logistic regression analyses were used to determine predictors of a positive scan for both cohort of patients. Regression-based coefficients were used to develop nomograms predicting scan positivity and extra-pelvic disease. Decision curve analysis (DCA) was implemented to quantify nomogram's clinical benefit. Of the 127 (63%) post-radical prostatectomy patients, 91 patients had positive scans - 61 of those with intrapelvic lesions and 30 with extra-pelvic lesions (i.e., retroperitoneal or distant nodes and/or bone/organ lesions). Of the 72 post-radiation therapy patients, 65 patients had positive scans - 39 of them had intrapelvic lesions and 26 extra-pelvic lesions. In the radical prostatectomy cohort, multivariate regression analysis revealed original International Society of Urological Pathology category, prostate-specific antigen (PSA), prostate-specific antigen doubling time (PSAdt), and time from BCR (mo) to scan were predictors for scan positivity and presence of extra-pelvic disease, with an area under the curve of 80% and 78%, respectively. Positive versus negative tumor margin after radical prostatectomy was not related to scan positivity or to the presence of positive extra-pelvic foci. In the radiation therapy cohort, multivariate regression analysis revealed that PSA, PSAdt, and time to BCR (mo) were predictors of extra-pelvic disease, with area under the curve of 82%. Because only seven patients in the radiation therapy cohort had negative scans, a prediction model for scan positivity could not be analyzed and only the presence of extra-pelvic disease was evaluated. PSA and PSAdt are consistently significant predictors of 18F-DCFPyL PET/CT positivity and extra-pelvic disease in BCR prostate cancer patients. Stratifying the patient population into primary local treatment group enables the use of other variables as predictors, such as time since BCR. This nomogram may guide selection of the most suitable candidates for 18F-DCFPyL-PET/CT imaging.

SALVAGE RADIOTHERAPY IN RELAPSED/REFRACTORY LARGE B‐CELL LYMPHOMA AFTER CAR T‐CELL THERAPY FAILURE

Introduction: We sought to describe our experience with salvage radiation therapy (RT) relative to other therapies in patients with relapsed/refractory large B-cell lymphoma (LBCL) post-CD19-targeted chimeric antigen receptor (CAR T)-cell therapy failure. Methods: A multi-institutional retrospective study was conducted in a database of 352 consecutive LBCL patients who received axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) between 2017 and 2021. Patients who relapsed following CAR T-cell therapy and received salvage therapies (RT alone, systemic therapy alone, or combined modality therapy [CMT]) were identified and analyzed. A separate analysis was then conducted for patients who were treated with comprehensive versus focal RT. Results: A total of 120 patients with post-CAR T relapsed LBCL received salvage therapies (RT alone, 14 patients; CMT, 40 patients; systemic therapy alone, 66 patients). The median follow-up after CAR T-cell infusion was 10.2 months (interquartile range [IQR]: 5.2–20.9 months). Failure occurred in previously involved sites prior to CAR T-cell therapy in 78% of patients (n = 93). The median time from CAR T-cell therapy infusion to the start of salvage therapy was 3.4 months (IQR: 1.7–6.5 months). A total of 93 sites were irradiated among the 54 patients who received RT in the RT and CMT cohorts. The median dose/fractionation were 30 Gy (range 4–50.4 Gy) and 10 fractions (range 1–28 fractions). The 1-year local control (LC) rate for the 81 assessable sites was 84%. The median overall survival (OS) from the time of salvage therapy was not reached for the RT group, 10.5 months for the CMT group, and 6.6 months for the ST group (p = 0.4). The median OS from the start date of RT was significantly higher among patients who received comprehensive RT versus focal RT (19.1 months vs. 3.0 months, p ≤ 0.001); 26 of the 29 patients who received comprehensive RT had only a single site of disease, but survival for the 3 patients with >1 site of disease was not statistically different (p = 0.17). Receipt of bridging therapy and CAR T construct were not significantly associated with OS after CAR T infusion. On multivariate survival analysis, achieving PR or CR post-CAR T (HR = 0.5, 95% CI: 0.3–0.9, p = 0.01) was independently associated with superior OS. Keywords: aggressive B-cell non-Hodgkin lymphoma, cellular therapies, radiation therapy No conflicts of interests pertinent to the abstract.

Patient-reported quality of life in adolescents and young adults with cancer who received radiation therapy.

Radiation therapy (RT) is a common treatment for adolescents and young adults (AYAs, 15-39 years old) with cancer; however, it may cause toxicities that affect health-related quality-of-life (HRQOL). Thus, we assessed HRQOL in AYAs before, during, and after RT. We identified 265 AYAs who completed HRQOL PROMIS® surveys before (n = 87), during (n = 84), or after (n = 94) RT. Higher PROMIS® score represents more of the concept. Mean scores were compared to the general US population and minimally important differences (MIDs) were used to evaluate the impact of cancer on HRQOL. Linear regression modeling was used to evaluate the effect of clinical and demographic factors on PROMIS scores. Median [IQR] age was 26 [20-31] years. Cancer types varied; most had sarcoma (26%) or CNS malignancy (23%). Compared to the general US population, the before RT cohort had worse anxiety (mean score 55.2 vs. 50, MID 3, p < 0.001) and the during RT cohort had worse global physical health (mean score 44.9 vs. 50, MID 5, p < 0.001). In the during RT cohort, patients with regional/distant disease had significantly worse pain (B = 15.94, p < 0.01) and fatigue (B = 14.20, p = 0.01) than patients with localized disease. In the after RT cohort, adolescents (15-18 years) and young adults (26-39 years) had worse global physical health (B = -6.87, p < 0.01, and B = -7.87, p < 0.01, respectively) and global mental health (B = -6.74, p < 0.01, and B = -5.67, p = 0.01, respectively) than emerging adults (19-25 years). AYAs with cancer receiving RT experience impairments in various domains of HRQOL. Advanced cancer stage may contribute to poorer short-term HRQOL and developmental stage may contribute to differing long-term HRQOL.

Treatment Disparities in Radiation and Hormone Therapy Among Women Covered by Medicaid vs Private Insurance in Cancer Registry and Claims Data

Prior research has reported undertreatment among patients with cancer who are insured by Medicaid, but this finding may be due, in part, to incomplete data in cancer registries. To compare disparities in radiation and hormone therapy between women with breast cancer covered by Medicaid and those with private insurance using the Colorado Central Cancer Registry (CCCR) and CCCR data supplemented with All Payer Claims Data (APCD). This observational cohort study included women aged 21 to 63 years who received breast cancer surgery. We linked the CCCR and Colorado APCD to identify Medicaid and privately insured women who were newly diagnosed with invasive, nonmetastatic breast cancer between January 1, 2012, and December 31, 2017. In the radiation treatment analysis, we narrowed the sample to women who received breast-conserving surgery (Medicaid, n = 1408; private, n = 1984) and in the hormone therapy analysis, we selected women who were hormone-receptor positive (Medicaid, n = 1156; private, n = 1667). We used logistic regression to estimate the likelihood of treatment within 12 months to assess whether the results varied between data sources. There were 3392 and 2823 participants in the radiation and hormone therapy cohorts, respectively. The mean (SD) age was 51.71 (8.30) years in the radiation therapy cohort, and 52.00 (8.16) years in the hormone therapy cohort. Among the participants, there were 140 (4%) and 105 (4%) who were Black non-Hispanic, 499 (15%) and 406 (14%) who were Hispanic, 2602 (77%) and 2190 (78%) were White, and 151 (4%) and 122 (4%) were other/unknown in the radiation and hormone therapy cohorts, respectively. A higher percentage of women were aged 50 years or younger in the Medicaid samples (40% vs 34% in the privately insured sample) and identified as non-Hispanic Black (about 7%) or Hispanic (approximately 24%). Treatment was underreported in both sources, but to a lesser extent in the APCD (2.5% and 2.0% for Medicaid and private insurance, respectively) compared with CCCR (19.5% and 13.3% for Medicaid and private insurance, respectively). Using CCCR data, Women with Medicaid insurance were 4 (95% CI, -8 to -1; P = .02) and 10 (95% CI, -14 to -6; P < .001) percentage points less likely to have a record of radiation and hormone therapy compared with privately insured women, respectively. Using combined CCCR and APCD, no statistically significant disparity was observed in radiation or hormone therapy between Medicaid-insured and privately insured women. Among women with breast cancer covered by Medicaid vs private insurance, cancer treatment disparities may be overestimated if based solely on cancer registry data.

Trends and Impact of Treatment Modalities (Surgery and Radiation Therapy) on Health Care Utilization in Patients With Glomus Jugulare Tumors (GJTs): An Inverse Probability of Treatment Weight Analysis

The trend of practice pattern and impact on health care utilization for surgery and radiation therapy (RT) in patients with glomus jugulare tumors (GJTs) is not well defined. The IBM (Armonk, NY) MarketScan database was queried using the ICD-9/10 and CPT 4th edition, 2000-2020. We included patients ≥18 years of age who underwent either surgery or RT with at-least 1-year follow-up. We compared the health care utilization at 3-month, 6-month, and 1-year follow up using the inverse probability of treatment weight technique. A cohort of 333 patients was identified. Of these, 72.7% (n= 242) underwent RT and 27.3% (n= 91) underwent surgery. RT use increased from 2002-2004 (50%) to 2017-2019 (91%). Patients in the surgery cohort were younger (median age 49 vs. 56 years, P < 0.0001) and had a higher 3+ comorbidity index (34% vs. 30%, P= 0.43) compared with patients in the RT cohort. Patients who underwent surgery had higher complications at index hospitalization (22% vs. 6%, P < 0.0001) and at 30 days (14% vs. 5%, P= 0.0042). No difference in combined index and 6- or 12-month payments were noted (6-months: surgery, $66m108, RT: $43m509, P= 0.1034; 12-months: surgery, $73,259, RT: $51,576, P= 0.1817). Only 4% of patients who had initial RT underwent RT and none underwent surgery at 12 months, whereas 6% of patients who had initial surgery underwent RT and 2% underwent surgery at 12 months. RT plays an increasingly important role in the treatment for patients with GJTs, with fewer complications and a comparable health care utilization at 1 year.

Why We Should Look at Dinner Plates: Diet Changes in Cancer Patients

Malnutrition is often underestimated in the context of cancer therapy: the dietary trends initiated by patients after diagnosis are usually neither known to nor evaluated by the medical staff. Here, we propose a combined screening instrument evaluating malnutrition and dietary trends. The validated screening tool NRS-2002 was combined with a four-item questionnaire assessing whether (1) patients preferred certain foods, (2) avoided certain foods, (3) used dietary supplements or followed a special diet since the time of cancer diagnosis. The screening tool was routinely used by cancer patients in the daily practice of three oncological departments. The presented analysis was performed retrospectively and anonymized. Overall, 102 cancer patients undergoing systemic therapy (CP), 97 undergoing radiation therapy (RP), and 36 head-neck cancer patients (HNP) were screened. The CP cohort showed a higher rate of malnutrition (50.00%) than the HNP (28.13%) or RP (26.80%) cohort. Overall, diet changes were observed in 33.63% of all patients. Avoiding meat, stimulants, or hard and edgy food was often mentioned in free text answers, while patients reported a preference for fruit and vegetables. Nutritional supplements were used by 28.76% of the patients. While dietary changes were common, only 6.64% of the patients mentioned adhering to a specific cancer diet. Malnutrition is still underestimated nowadays. Diet trends, especially avoiding certain foods, are common in cancer patients, while adhering to a specific cancer diet is an exception. Diet trends should be assessed and addressed to avoid or aggravate malnutrition.

Effect of Radiation Therapy on Outcomes after CAR T-Cell Therapy for Non-Hodgkin Lymphoma

<h3>Purpose/Objective(s)</h3> Patients (pts) who receive CD19 CAR T-cell therapy (CART) for non-Hodgkin's Lymphoma (NHL) with high-risk features, including bulky disease (dz) and increased inflammatory markers, are at higher risk of CART failure. The impact of radiation therapy (RT) on post-CART outcomes is poorly understood and is thus assessed here. <h3>Materials/Methods</h3> We retrospectively analyzed 133 pts who received CART for NHL from 01/2018 – 07/2021 at a single academic center. We compared pts who received RT within 100 days prior to CART infusion, either as bridging or as salvage prior to leukapheresis (RT cohort), and those who did not (no-RT cohort). Tumor ≥ 5cm defined bulk. Progression free survival (PFS) and overall survival (OS) were analyzed by Kaplan-Meier method and Cox regression modeling. Associations between RT and covariates were evaluated by Fisher's exact tests. <h3>Results</h3> 15 pts received RT, 11 as bridging and 4 prior to leukapheresis due to symptoms/bulk. Median time from RT to CART infusion was 12 days. There were no significant differences in baseline pt and dz characteristics between the 2 cohorts. In RT vs no-RT pts, bulk was present in 73% vs 54% (p=0.27) and ferritin was increased (> 290 ng/ml) in 93.3% vs 68.4% (p=0.065). More RT pts received axicabtagene ciloleucel (axi-cel) at 66.7% vs 48.3% (p=0.022). In all pts, use of systemic or any bridging therapy was associated with worse OS (HR 2.8, p<.01; 3, p<.001) and PFS (HR 1.9, p<.01; HR 2.1 p<.01) while RT bridging was not (HR 1.5, p=0.48; HR 1, p=0.9). Bulky dz, higher ECOG, and increased inflammatory markers were also associated with inferior PFS/OS. The RT cohort had a best overall response rate (ORR) of 84.6% vs 60.7% in no-RT pts (p=0.13). Median f/up was 17.2 months (mo). For the RT and no-RT cohorts, median PFS was 22 mo and 7.2 mo; median OS was not reached for RT and was 39 mo for no-RT. PFS/OS were not statistically different. There were no differences in cytokine release syndrome (CRS). RT pts had more grade ≥ 3 neurotoxicity at 53.3% vs. 18.6% (p=0.006). At day 90 post-CART, RT pts had less neutropenia at 7.7% vs. 38.3% (p=0.03) and less grade ≥3 neutropenia at 0% vs. 22.5% (p=0.04). For pts w/ bulky dz, ORR was 77.8% with RT vs. 52.5% w/o RT (p=0.28). Median RT dose for all RT pts was 29.4 Gy (range 22.5-60) delivered in median of 10 fractions (range: 9-24). RT pts w/ bulky dz received a median of 25 Gy (range: 22.5-60) also delivered in median of 10 fractions (range: 9-24). In pts w/ bulk, relapse occurred locally in 57.1% of RT pts vs. 88.6% of no-RT pts (p=0.06). <h3>Conclusion</h3> Pts who received RT had similar outcomes to those who did not and trended towards decreased local relapse. RT pts had more neurotoxicity; this may have been confounded by increased use of axi-cel and trends towards increased inflammatory markers and increased bulky dz. Reduced neutropenia in RT pts was a novel finding. Our data support further multi-center studies to investigate the role of RT in mitigating CART failure in NHL pts with high-risk, bulky dz.

“Supermassive” Intrahepatic Cholangiocarcinoma: The Role of Ablative Radiation Therapy

<h3>Purpose/Objective(s)</h3> Ablative radiation therapy (RT) has been shown to improve clinical outcomes in patients with unresectable intrahepatic cholangiocarcinoma (ICC). Here we report on a cohort with "supermassive" ICC, and assess the role of ablative RT in the treatment of patients with such large lesions. <h3>Materials/Methods</h3> We retrospectively collected data from the University of Texas MD Anderson Cancer Center on patients presenting with ICC. We identified 63 patients with unresectable ICC, with tumors having a diameter of 10cm or more (34 received RT with or without chemotherapy, and 29 received chemotherapy alone). All patients in the RT cohort were treated with biologically effective doses (BED) higher than 80.5Gy. We analyzed overall survival (OS), tumor-related liver failure (TRLF), and treatment toxicity. <h3>Results</h3> Patients were followed-up to a median of 17.9 months. In total, 48 patients died (76.2%): 22 (64.7%) in the RT cohort and 26 (89.7%) in the chemotherapy cohort. Patients who received RT showed improved OS compared to patients in the chemotherapy cohort (Median OS 28.7 vs 11.9 months, respectively, log-rank <i>P</i>=0.003; aHR=0.3, 95%CI 0.1-0.7, <i>P</i>=0.01). Patients treated with chemotherapy alone had a higher rate of TRLF compared to those who received RT (47.1% vs 12.1%, respectively, log-rank <i>P</i>=0.01). No grade 3 or higher acute RT toxicity was noted. <h3>Conclusion</h3> Patients with "supermassive" ICC treated with ablative RT showed excellent clinical outcomes, with tolerable toxicity. Future studies are still needed to better assess the role of RT in this patient population.

Short-Course Palliative Radiotherapy Combined With Immunotherapy for Recurrent/Advanced/Metastatic Head and Neck Cancer

To evaluate tumor response rates in patients treated with a combination of palliative short-course radiotherapy (SCRT) and immune checkpoint inhibitor immunotherapy (IO) in patients with recurrent, advanced or metastatic (R/A/M) head and neck cancer (HNC).We reviewed the medical records of patients treated with short-course palliative intent radiation therapy (RT) (hypofractionated RT in 4-5 fractions) for R/A/M HNC between 2014-2020. Patient, disease, and treatment factors were abstracted from the medical record. Patients were categorized as having been treated with combined immunotherapy and radiotherapy (IO+RT) if the RT was given after at least 1 cycle of IO with at least 1 cycle of IO afterward. Treated gross tumor volume (GTV) was measured prior to and after RT and percent change in GTV volume from baseline to best overall response (BOR) was calculated. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method.In total, 19 patients were treated with SCRT, 7 of whom were treated with combined IO+RT. Primary site included oral cavity (n = 6), larynx/hypopharynx (5), oropharynx (3), sinonasal (2), cutaneous (2), and thyroid (1). Squamous cell histology was most frequent (16/19) with the other 3 comprised of sinonasal intestinal-type adenocarcinoma, mucosal melanoma, and Hürthle cell carcinoma. Disease status included 6 patients with a recurrence, 6 were metastatic, 3 locally advanced/incurable, and 3 recurrent/metastatic. Prior treatments included RT (n = 9) and chemotherapy (6); ECOG performance status was 1-2 in 13 patients and 3-4 in 6 patients. Seventeen patients were treated with "quad-shot" radiotherapy (14.4-14.8 Gy in 4 fractions delivered twice daily) and 2 were treated with 20 Gy in 5 fractions. Median (range) number of IO cycles given pre- and post-RT were 7 (1-11) and 2 (1-21), respectively. Of the 17 evaluable patients for treatment response, 13 patients responded or were stable while 4 had progression. Median pre-RT target volume in the RT cohort was 37.2 (6.14-486.21) cc and 145.28 (24.21-219.51) cc in the IO+RT cohort. Median post-RT target volume in the RT cohort was 28.00 (17.23, 57.630 cc and 58.44 (0.00, 246.56) cc in the IO+RT cohort. Median change in target volume in RT cohort was -42% (range: -100, 259) cc and -54% (-100, 12) cc in the IO+RT cohort. 1-year PFS and OS were 5% and 21%, respectively. 1-year OS was numerically higher for IO+RT patients (43% v. 8%, P = 0.13).In this select cohort of patients with R/A/M HNC, combined IO+SCRT was feasible and showed an improved tumor response as evidenced by greater decrement in post-treatment tumor volume. An ongoing clinical trial (NCT04454489) aims to prospectively evaluate the potential benefit of combined quad-shot radiotherapy with Pembrolizumab to improve response rates to IO alone.

Clinical Outcomes of Post-Transplant Lymphoproliferative Disease (PTLD): Role of Radiation Therapy in Improvement of Disease Response

Post-transplant lymphoproliferative disease (PTLD) is a rare disease complicating solid organ transplantation (SOT) and hematopoietic cell transplantation (HCT). Management of PTLD includes immunosuppression reduction, systemic therapy, surgery and radiation therapy (RT). Data regarding the efficacy and outcomes of radiation therapy in treatment of PTLD is limited. Here, we report our institution's experience with the treatment of PTLD including RT outcomes.We retrospectively reviewed patients with biopsy proven PTLD who were treated at our institution. After obtaining Institutional Review Board approval, patient demographics, disease characteristics, treatment modalities and follow-up data were recorded. Disease response before and after RT use was assessed per response evaluation criteria in solid tumors (RECIST) 1.1 including complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan Meier method. Cox Proportional Hazards models were utilized to determine variables associated with OS.We identified and reviewed medical records of 48 patients with PTLD. Median follow up was 38 months. The median age was 58 (range:10-81). The majority were white (79%) and male (56%). 50% of the cohort were SOT recipients, 44% were HCT recipients and 6% underwent combined transplants. The most common site of PTLD was CNS (29%). Monomorphic PTLD was the most common histological type with EBV positivity in 75% of patients. Median time from SOT-to-PTLD was 77 months (range:5-322) and HCT-to-PTLD was 5 months (range: 2-46). Systemic therapy was the most commonly used modality in 92% of patients. The most commonly used regimen was Rituximab monotherapy. Surgery was employed in 10% of patients. RT was utilized after induction therapy in 37.5%. The most common treated site was the brain (61%). Overall response of the entire cohort was 87% (58% CR and 29% PR), 6% achieved SD and 7% had PD. Among the RT cohort, 55% achieved CR, 33% achieved PR and 12% had SD. Local control rate was 100%. Of 21 patients who did not respond completely to induction therapy, 6 patients with initial PR achieved CR, 1 patient with initial SD achieved CR, 1 patient with initial PD achieved CR, and 2 patients with initial PD achieved PR and SD, respectively, after RT receipt. The median RT dose was 3,600 cGy (range: 2400-4600). 3- and 5-year PFS were 90% and 85%, respectively, while 3- and 5-year OS were 70% and 55%, respectively. Cox hazards modeling confirmed that HCT receipt was associated with better OS on multivariate analysis (HR 0.26, 95% CI 0.008- 0.671, P = 0.007).RT provides excellent local control and improves overall disease response of PTLD. Further optimization and standardization of combined modality paradigms are needed to improve clinical outcomes of this rare entity.

Surgery versus radiation therapy outcomes in patients with clinical stage 0 non-small cell lung cancer.

e20537 Background: There are currently no clear national guidelines for management of in-situ (stage 0) non-small cell lung cancer (NSCLC). With no prospective clinical trial data, treatment strategies include both surgical resection and definitive radiation therapy (RT). We aimed to investigate survival outcomes in patients with stage 0 NSCLC who underwent surgery or RT. We also aimed to identify any differences in the treatments that the two groups received with respect to rural versus urban setting and racial variation. Methods: The 2016 National Cancer Data Base was reviewed from 2006-2015 for patients registered with a pathological diagnosis of Stage 0 NSCLC, based on the AJCC 7th edition classification for lung cancer. Patients with a prior history of malignancy, secondary malignancy other than lung, and contraindications to surgery were excluded. Univariate comparison and multivariate logistic regression modeling were utilized to identify factors associated with receipt of surgery. Patients were stratified into two groups, surgical resection and RT. Kaplan-Meier estimators and Cox proportional-hazards regression were used to compare overall survival(OS). Propensity score matching was performed using relevant demographic and clinical factors associated with receipt of surgery. All analysis was completed in SAS version 9.4 and p-values less than 0.05 were considered significant. Results: A total of 156 patients were identified with Stage 0 NSCLC who received surgery (n = 104) or RT (n = 52). Surgery was defined as lobectomy or less. Histologic subtypes were squamous cell carcinoma (54%), adenocarcinoma (45%), and bronchioloalveolar carcinoma (1%). Median age was 65 years for the surgical resection cohort and 70 years for the RT cohort. From diagnosis, median time to surgery was 21 days for the surgical resection cohort and 47 days to start of radiation for RT cohort. We did not identify any major differences with respect to rural versus urban setting or racial differences within the surgery and RT cohorts. Patients who underwent surgical resection had a superior 5 year overall survival 65% (CI, 43.49-80.56) when compared to patients who underwent RT 37% (CI, 10.63-65.05), hazard rate 0.403, p = 0.0009, 95% CI. 0.236 – 0.689). Conclusions: Our findings show a significant improved survival with surgical resection compared to RT in patients diagnosed with Stage 0 NSCLC.

Healthcare resource utilization following unilateral versus bilateral radiation therapy for oropharyngeal carcinoma

PurposeTo describe differences in healthcare resource utilization between patients treated with bilateral vs. unilateral neck radiation therapy (RT) for lateralized oropharyngeal cancer. MethodsA propensity score matching strategy was used to identify two otherwise clinically similar cohorts of tonsillar cancer patients treated with either bilateral or unilateral neck RT. Cohorts were matched based on similar propensity scores for age, sex, ECOG performance status, pack-year smoking history, cT-category, cN-category, HPV-status, and use of concurrent chemotherapy. Short term (from start of RT to 3 months following end of RT) resource utilization included: 1) outpatient supportive care visits, 2) hospital admission, and 3) interventions (feeding tube insertion and outpatient intravenous hydration). Long-term resource utilization included feeding tube dependency at 1-year. ResultsAmong 559 patients with tonsillar cancer treated between 2004–2017, propensity score matching identified a unilateral neck RT cohort (n = 81) and bilateral neck RT cohort (n = 81) with similar clinical and treatment characteristics. Bilateral neck RT was associated with a higher likelihood of hospitalization (33% vs 12%, p < 0.01), outpatient IV hydration (33% vs 17%, p = 0.03), and feeding tube insertion (33% vs 10%, p < 0.001); a greater number of total days of hospitalization (110 vs 47 days, p < 0.01) and outpatient IV hydration (135 vs 72 days, p = 0.02); and higher total number of supportive clinic visits (1226 vs 1053 days, p = 0.04). In the long-term, bilateral RT was associated with higher rate of feeding tube dependency at 1-year (7% vs 0%, p < 0.001). ConclusionBilateral RT for tonsillar cancer resulted in significant increase in health resource utilization.

The use of virtual reality computed tomography simulation within a medical imaging and a radiation therapy undergraduate programme.

IntroductionThe use of virtual reality (VR) simulation in the education of healthcare professionals has expanded into the field of medical radiation sciences. The purpose of this research was to report on the student experience of the integration of VR education for both medical imaging (MI) and radiation therapy (RT) students in learning computed tomography (CT) scanning.MethodsA survey was performed to evaluate students’ perceived confidence in performing diagnostic and planning CT scans in the clinical environment following VR CT simulation tutorials. Students from both MI and RT participated in providing quantitative and qualitative data.ResultsThe MI students (n = 28) and RT students (n = 38) provided quantitative results linking their engagement (perceived usefulness, ease of use, enjoyment) with their perceived confidence. The 15 (54%) MI students who recorded a maximum engagement score had a mean confidence score 1.02 higher than the students not fully engaged (Fisher’s exact test 14.549, P = 0.00). The results from the RT cohort revealed 68% of students agreed or strongly agreed to the addition of VR CT simulation helping in the learning of CT.ConclusionIt can be concluded that the integration of innovative learning opportunities such as VR CT simulation has the potential to increase student confidence and improve student preparation for the clinical environment.

Safety of nivolumab in combination with prior or concurrent radiation therapy in hepatocellular carcinoma

Nivolumab has been demonstrated to be effective for the treatment of unresectable hepatocellular carcinoma (HCC). While many patients may additionally benefit from radiation therapy (RT), the toxicity of combination nivolumab and RT is unknown. Patients who underwent liver-directed RT prior to or concurrent with nivolumab for HCC at our institution were reviewed. Toxicity was assessed by Common Terminology Criteria for Adverse Effects v5.0 criteria until disease progression, change in systemic therapy, additional liver-targeted locoregional therapy (LRT), or death. Prevalence ratios (PR) were compared for patients undergoing prior and concurrent RT. Childs-Turcotte-Pugh (CTP) and Albumin-Bilirubin (ALBI) scores at 1-, 3-, and 6-months were compared with baseline. We identified 55 patients with median follow-up 6.0 months; 34 (62%) received prior and 21 (38%) received concurrent RT. Grade 3+ toxicity occurred in 8 patients (17%). Grade 3+ toxicities did not differ between prior and concurrent RT cohorts on the univariable analysis (PR 1.91; 95% CI 0.42, 8.59) but were higher in the prior RT cohort on the multivariable analysis (PR 5.42; 95% CI 1.42, 20.67; p = 0.013). Mean CTP scores increased from baseline (6.33) at 1 month (7.04; 95% CI 6.80, 7.27) and 3 months (6.81; 95% CI 6.43, 7.19) and thereafter normalized; mean ALBI scores increased from baseline (− 1.93) at 1 month (− 1.75; 95% CI − 1.84, − 1.66) with no difference thereafter. Combination RT and nivolumab is generally safe in the management of unresectable HCC with a low rate of serious adverse events. Prospective trials investigating the efficacy of combination nivolumab and RT are warranted.

Radiation Therapy Can be an Effective Bridging Strategy Prior to Axicabtagene Ciloleucel Therapy for Relapsed/Refractory Large B-Cell Lymphoma

Radiation Therapy Can be an Effective Bridging Strategy Prior to Axicabtagene Ciloleucel Therapy for Relapsed/Refractory Large B-Cell Lymphoma

Comparison of Radiation Therapy and Radical Prostatectomy in the Treatment of High-Risk Prostate Cancer: A Retrospective Matched Pair Review

Both definitive radiation therapy (RT) ±androgen deprivation therapy (ADT) and radical prostatectomy (RP) + adjuvant RT±ADT are considered standard of care treatment regimens for patients with high risk prostate cancer. The ideal modality to treat this patient population and achieve disease control while also limiting treatment related toxicity remains debated. In this study, we utilized a retrospective matched pair analysis to compare survival and overall disease control outcomes relative to primary treatment modality. 1436 pts with National Comprehensive Cancer Network defined high risk prostate cancer diagnosed between August 1992 and October 2016 at a single institution were analyzed. All those eligible were treated with RP + adjuvant RT ±ADT (n=774) or definitive RT alone ±ADT (n=660), which consisted of either high dose rate (HDR) brachytherapy boost together with pelvic external beam RT (EBRT) or dose-escalated, adaptive radiation therapy (ART). A 1:1 matched pair analysis was completed, which paired 196 pts based on three poor prognostic characteristics: pre-treatment prostate-specific antigen (PSA) ≥ 20, Gleason score ≥ 8, and clinical T stage ≥T2c. There were 98 pts in both the RT and RP cohorts for this analysis. The average age of the RT and RP groups were 66.4 years and 66.7 years respectively. The median follow-up for those treated with RP was 13.6 years, while those treated with RT was 8.96 years. 21 (21.4%) treated with RP had ≥ T2c disease, while 37 (37.7%) treated with RT had ≥T2c disease. 40.8% in both the RP and RT cohorts had Gleason score ≥ 8. 37.8% of pts had a pre-treatment PSA ≥ 20 in both the RP and RT cohorts. 5 pts (5.1%) in both the RP and RT cohorts received ADT. 37 (37.7%) in the RT cohort were treated with HDR combined with EBRT, while 61 (62.2%) of the RT cohort were treated with ART. There was no statistical difference between pts treated with RT and those treated with RP for overall survival (p =0.21), cause specific survival (p=0.28), or distant disease control (p=0.88). RT was statistically superior compared to RP in regard to locoregional control (p=0.015). When analyzing the two modalities of RT used to treat high risk prostate cancer in this patient cohort compared to RP, both ART and HDR were statistically superior compared to RP in regard to locoregional disease control (p=0.049). Based on this retrospective matched pair analysis of 196 pts with high risk prostate cancer, the addition of radical prostatectomy to locoregional RT did not improve survival or locoregional disease control rates. Neither approach was associated with improved long-term survival, and locoregional disease control was superior in pts treated with definitive RT.