Delay In Radiotherapy Research Articles

Impact of weight loss on treatment interruption and unplanned hospital admission in head and neck cancer patients undergoing curative (chemo)-radiotherapy in Hong Kong.

Malnutrition is highly prevalent in head and neck cancer (HNC) patients, with weight loss being one of the major nutritional indicators. The objective of this study was to investigate the impact of weight loss on treatment interruptions and unplanned hospital admissions in HNC patients undergoing radiotherapy (RT) with or without chemotherapy. In this retrospective cohort study, consecutive HNC patients who started RT between January 2011 and December 2019 were included. Data from a total of 1086 subjects with 747 (68.8%) nasopharyngeal carcinomas (NPCs) and 31.2% (N=339) non-NPC patients were analysed. Body weight (BW) was measured before, during, and after RT treatment. Factors associated with ≥10% weight loss, treatment interruption, and unplanned admissions were analysed using multivariate logistic regression. The prevalence of ≥10% weight loss was 26.8% (N=288), with 32.7% (N=243) in NPC and 13.5% (N=45) in non-NPC patients. The prevalence of RT delay in patients with ≥10% vs. <10% weight loss was 6.2% vs. 7.0% (p=0.668) in NPC patients and 42.2% vs. 50.5% (p=0.300) in non-NPC patients. The prevalence of unplanned admissions in patients with ≥10% vs. <10% weight loss was 51.9% vs. 25.3% (p<0.001) in NPC patients and 68.9% vs. 27.0% (p<0.001) in non-NPC patients. In our study, ≥10% weight loss was found to be associated with a higher rate of unplanned admissions but not with RT delay or chemotherapy interruption. With the knowledge of the impact of weight loss on hospital admissions and the characteristics of patients with weight loss, nutritional intervention can be effectively focused on the stratification of patients for intensive nutritional support to reduce weight loss.

Anal carcinoma: A retrospective analysis in a Mexican cohort.

e15502 Background: Anal carcinoma is a rare neoplasm, representing &lt; 1% of all neoplasms with rising incidence and mortality. More than 90% of cases are linked with high-risk human papillomavirus (HPV). Other factors such as HIV status, smoking and socioeconomic disparity may have important roles. Few data are available on the Mexican population. Methods: Retrospective analysis of patients with pathology-confirmed anal carcinoma treated at an Oncology Reference Center in North-East Mexico from 2010 to 2020. Using descriptive statistics, we report clinical and pathological features, time from symptom onset to diagnosis and treatment, as well as response and recurrence rate. Results: Forty-one patients were included in the final analysis. The mean age at diagnosis was 61.4 +/- 13.8 years and 58.5% were women. Smoking history was identified in 17 patients (41.5%). 9.8% were HIV-positive, however 63.4% of all patients had unknown status at cancer diagnosis. Mean duration of symptoms to diagnosis was 344 days (range 4-1435 days) and the median interval from symptom onset to registration for oncology consultation was 424 days (range 28-1695 days). Patients attended a median of 3 (range 1 to 7) previous clinical consultations before being referred to our center. It is noteworthy that 44% of patients had hemorrhoidal disease history. Squamous cell carcinoma was the most common histological subtype with 93% of all cases, arising from the anal canal in 78% of cases, while 22% corresponded to perianal cancer. Regarding the clinical stage at presentation, 2.4% of patients had localized disease, while 95% had regional spread and 2.4% presented with distant metastases at diagnosis. Treatment intent was curative in 85.4%. Treatment modalities included radiotherapy (97%), surgery (7%), chemotherapy (88%). Concurrent chemoradiotherapy was received by 85%. Most patients were treated with a total dose between 45 and 60 Gy to the tumor volume. Radiotherapy delays due to toxicity occurred in 31.7% of cases, these unplanned treatment interruptions correlated negatively with response rate (p &lt; 0.001). The chemotherapy regimen used was 5-fluorouracil (5-FU) with mitomycin C (MMC) in 29%, capecitabine monotherapy in 31.7%, 5-FU with cisplatin in 12.5%, capecitabine with MMC in 5%, and capecitabine with cisplatin in 5%. Among patients treated with curative-intent, 46% had a complete response and 37% had a partial response. Relapse occurred in 10 cases (24%), the majority being local relapses (54%). Distant relapse occurred in 15% of all cases. The median disease-free interval (DFI) was 32.5 months (range 0-252 mo). Colostomy rate was 29%, the median colostomy-free survival (CFS) was 10 months (range 3-15 mo). The comparative analysis between MMC-based chemotherapy and chemo without MMC did not show difference in response rate, recurrence, DFS and CFS. Conclusions: Due to its rarity and complex management patients with anal carcinoma should be treated at experienced centers.

The efficacy of Mecapegfilgrastim therapy in the primary prevention of concurrent chemoradiotherapy-induced neutropenia

ObjectiveTo evaluate the efficacy and safety of mecapegfilgrastim therapy in primary prevention of neutropenia after concurrent chemoradiotherapy for cervical cancer. MethodsThis study was a single-center, open, one-arm clinical observation, and analyzed the effectiveness of mecapegfilgrastim primary prevention of neutropenia after concurrent chemoradiotherapy in 25 cervical cancer patients undergoing concurrent chemoradiotherapy in Tianjin Medical University Cancer Institute and Hospital from 2019 to 2021. ResultsDuring the whole concurrent chemorrhotic cycle, chemotherapy delay occurred in 8 patients, (16%). The completion rate of chemotherapy cycle was 84% (42/50). There were only 4 (8%) cases of delayed concurrent chemotherapy due to leukopenia or neutropenia. Radiotherapy delay occurred in 10 patients, (20%). None of the patients delayed radiotherapy due to leukopenia or neutropenia. The incidence of febrile neutropenia (FN) was 0%. Subgroup analysis found that after completing 1 cycle of concurrent chemoradiotherapy, 6(12%) patients with grade 3–4 leukocyte or neutropenia. After completing 2 cycles of concurrent chemoradiotherapy, 14(29%) patients with grade 3–4 leukocyte or neutropenia. ConclusionDuring the chemoradiation in patients with cervical cancer, primary prevention use of mecapegfilgrastim can significantly reduce the incidence of FN, effectively reduce the incidence of grade III-Ⅳ leukopenia or neutropenia, beneficial to ensure the smooth progress of concurrent chemoradiotherapy,and provide a new direction for primary prevention of cervical cancer chemotherapy.

Outcomes of SARS-CoV-2 infection in 126 children and adolescents with central nervous system tumors.

The Global Registry of COVID-19 in Childhood Cancer (GRCCC) seeks to describe the natural history of SARS-CoV-2 in children with cancer across the world. Here, we report the disease course and management of coronavirus disease 2019 (COVID-19) infection in the subset of children and adolescents with central nervous system (CNS) tumors who were included in the GRCCC until February 2021, the first data freeze. The GRCCC is a deidentified web-based registry of patients less than 19years of age with cancer or recipients of a hematopoietic stem cell transplant and laboratory-confirmed SARS-CoV-2 infection. Demographic data, cancer diagnosis, cancer-directed therapy, and clinical characteristics of SARS-CoV-2 infection were collected. Outcomes were collected at 30 and 60days post infection. The GRCCC included 1500 cases from 45 countries, including 126 children with CNS tumors (8.4%). Sixty percent of the cases were from middle-income countries, while no cases were reported from low-income countries. Low-grade gliomas, high-grade gliomas, and CNS embryonal tumors were the most common CNS cancer diagnoses (67%, 84/126). Follow-up at 30days was available for 107 (85%) patients. Based on the composite measure of severity, 53.3% (57/107) of reported SARS-CoV-2 infections were asymptomatic, 39.3% (42/107) were mild/moderate, and 6.5% (7/107) were severe or critical. One patient died from SARS-CoV-2 infection. There was a significant association between infection severity and absolute neutrophil count less than 500 (p=.04). Of 107 patients with follow-up available, 40 patients (37.4%) were not receiving cancer-directed therapy. Thirty-four patients (50.7%) had a modification to their treatment due to withholding of chemotherapy or delays in radiotherapy or surgery. In this cohort of patients with CNS tumors and COVID-19, the frequency of severe infection appears to be low, although severe disease and death do occur. We found that greater severity was seen in patients with severe neutropenia, although treatment modifications were not associated with infection severity or cytopenias. Additional analyses are needed to further describe this unique group of patients.

Stereotactic Body radiotherapy and pedicLE screw fixatioN During one hospital visit for patients with symptomatic unstable spinal metastases: a randomized trial (BLEND RCT) using the Trials within Cohorts (TwiCs) design

BackgroundSpinal metastases can lead to unremitting pain and neurological deficits, which substantially impair daily functioning and quality of life. Patients with unstable spinal metastases receive surgical stabilization followed by palliative radiotherapy as soon as wound healing allows. The time between surgery and radiotherapy delays improvement of mobility, radiotherapy-induced pain relief, local tumor control, and restart of systemic oncological therapy. Stereotactic body radiotherapy (SBRT) enables delivery of preoperative high-dose radiotherapy while dose-sparing the surgical field, allowing stabilizing surgery within only hours. Patients may experience earlier recovery of mobility, regression of pain, and return to systemic oncological therapy. The BLEND RCT evaluates the effectiveness of SBRT followed by surgery within 24 h for the treatment of symptomatic, unstable spinal metastases.MethodsThis phase III randomized controlled trial is embedded within the PRospective Evaluation of interventional StudiEs on boNe meTastases (PRESENT) cohort. Patients with symptomatic, unstable spinal metastases requiring stabilizing surgery and radiotherapy will be randomized (1:1). The intervention group (n = 50) will be offered same-day SBRT and surgery, which they can accept or refuse. According to the Trial within Cohorts (TwiCs) design, the control group (n = 50) will not be informed and receive standard treatment (surgery followed by conventional radiotherapy after 1–2 weeks when wound healing allows). Baseline characteristics and outcome measures will be captured within PRESENT. The primary outcome is physical functioning (EORTC-QLQ-C15-PAL) 4 weeks after start of treatment. Secondary endpoints include pain response, time until return to systemic oncological therapy, quality of life, local tumor control, and adverse events up to 3 months post-treatment.DiscussionThe BLEND RCT evaluates the effect of same-day SBRT and stabilizing surgery for the treatment of symptomatic, unstable spinal metastases compared with standard of care. We expect better functional outcomes, faster pain relief, and continuation of systemic oncological therapy. The TwiCs design enables efficient recruitment within an ongoing cohort, as well as prevention of disappointment bias and drop-out as control patients will not be informed about the trial.Trial registrationClinicalTrials.gov NCT05575323. Registered on October 11, 2022.

Impact of radiotherapy delay following biopsy for patients with unresected glioblastoma.

Because of the aggressive nature of glioblastoma, patients with unresected disease are encouraged to begin radiotherapy within approximately 1 month after craniotomy. The aim of this study was to investigate the potential association between time interval from biopsy to radiotherapy with overall survival in patients with unresected glioblastoma. Patients with unresected glioblastoma diagnosed between 2010 and 2014 who received adjuvant radiotherapy and concurrent chemotherapy were identified in the National Cancer Database. Demographic and clinical data were compared using chi-square and Wilcoxon rank-sum tests. Survival was analyzed using the Kaplan-Meier method and Cox proportional hazards regression modeling. Among 3456 patients with unresected glioblastoma, initiation of radiotherapy within 3 weeks of biopsy was associated with a higher hazard of death compared with later initiation of radiotherapy. After excluding patients who received radiotherapy within 3 weeks of biopsy to minimize the effects of confounders associated with short time intervals from biopsy to radiotherapy, the median interval from biopsy to radiotherapy was 32 days (IQR 27-39 days). Overall, 1782 (66.82%) patients started radiotherapy within 5 weeks of biopsy, and 885 (33.18%) patients started radiotherapy beyond 5 weeks of biopsy. On multivariable analysis, there was no significant difference in overall survival between these two groups (HR 0.96, 95% CI 0.88-1.50; p = 0.374). In patients with unresected glioblastoma, a longer time interval from biopsy to radiotherapy does not appear to be associated with worse overall survival. However, external validation of these findings is necessary given that selection bias is a significant limitation of this study.

Head and neck cancer: hypofractionated adjuvant radiation therapy

INTRODUCTION: Effect of adiuvant radiation therapy (RT) on oncologic outcomes is well-known and confirmed by different trials. Optimal time to start RT is 6–8 weeks after surgery. Increasing duration of RT delay beyond that interval leads to decrease in overall survival (OS) and makes loco-regional recurrence (LRC) more probable. However, more than 50% patients do not receive adjuvant treatment in time (Mitra S. et al., 2022). Overall treatment time (77–100 days) is another factor that influences effectiveness of adjuvant RT. In order to keep within that time limits non-conventional regimens of RT can be used.OBJECTIVE: To test safety and feasibility of hypofractionated adjuvant RT in patients with locally advanced squamous cell carcinoma of oral cavity and oropharynx.MATERIALS AND METHODS: Patients with stage III–IV squamous cell carcinoma of oral cavity and oropharynx (n=11) who underwent surgery and have to recieve adjuvant RT in 8 weeks and more after surgery are included. Dose was delivered using Volumetric Modulated Arc Therapy (VMAT) and simultaneous integrated boost.RESULTS: Patients (n=11) completed RT successfully. Surgery-to-RT interval ranges between 9 and 15 weeks. Dose per fraction on high-risk-CTV varies between 2,5 and 2,75 Gy. Acute side-effects (oral mucositis grade II) presented after 27–32 Gy (11–13 fractions) in 9 patient out of 11 and reached maximum (oral mucositis grade III, radiation dermatitis grade II) at the end of the treatment.CONCLUSIONS: Hypofractionated adjuvant RT (VMAT) can be safely used in patients with locally advanced squamous cell carcinoma of oral cavity and oropharynx and local acute toxicity can be controlled.

Prediction of respiratory motion based on sequential embedding combined with relational embedding

To propose a deep learning model for modeling and prediction of the integration of respiratory motion in all directions. The respiratory motion signals in different directions were input into the sequential embedding layer composed of LSTM to capture the sequential dependence of the historical motion state and obtain the sequential embedding representation, which enabled relational embedding in all directions through the self-attention mechanism to obtain the relational embedding representation. The sequential embedding representation and the relational embedding representation were concatenated and input into a prediction layer consisting of a fully connected neural network to generate nonlinear prediction components, which were added to the linear prediction components generated by the autoregressive module parallel to the above structure to generate the final prediction. The model was trained using a 'pre-training + fine-tuning' approach. In the validation experiments, 304 respiratory motion trajectories were used for model pre-training, and 7 evaluation samples were used for model testing. The proposed prediction model achieved more accurate prediction results than other methods. For the 7 evaluation samples with different delay time, the proposed prediction model achieved a reduction of absolute deviations in the 3D directions by over 70%. The proposed model is capable of accurate prediction of respiratory motion and can thus help to reduce system delay in precise radiotherapy.

CTNI-66. THE PREOPERATIVE BRAIN IRRADIATION IN GLIOBLASTOMA (POBIG) STUDY: A NOVEL TREATMENT PARADIGM TO IMPROVE OUTCOMES?

Abstract OBJECTIVE The Preoperative Brain Irradiation in Glioblastoma (POBIG) study evaluates for the first time the safety, feasibility, and impact of single fraction preoperative radiotherapy in newly diagnosed glioblastoma patients. METHODS Operable patients with a radiological diagnosis of glioblastoma, by consensus of a multidisciplinary tumor board including two dedicated neuro-radiologists, are screened for the study. Anatomical and functional MRI sequences are acquired for further tumor characterization and preoperative radiotherapy planning. Radiotherapy is delivered approximately two weeks after the initial screening. Radiation targets the macroscopic and microscopic tumor region at risk of being left behind during surgery and spares at least 2cc tumor volume being debulked to safeguard unperturbed and clinically relevant tissue examination and molecular profiling. The study dose-escalates (from 8Gy to 14Gy) based on the time-to-event Continual Reassessment Methodology. Subsequently, patients undergo surgical debulking followed by postoperative fractionated radiotherapy 60Gy/30fr with concurrent temozolomide. RESULTS The first POBIG study patient underwent preoperative radiotherapy followed by a subtotal resection of a left posterior fronto-opercular tumor and completed the postoperative chemoradiotherapy. Screening, study consent, MRI imaging and analysis, radiotherapy planning and delivery until surgery can be achieved within three weeks from screening while maintaining adequate and personalized patient communication. There were no surgical or radiotherapy delays or complications. During surgery, we successfully sampled unirradiated and irradiated tumor regions. The radiotherapy field covered the whole remnant tumor, and image-guided obtained tumor samples and imaging analysis showed clear evidence of differential radiation-induced changes. CONCLUSION We successfully initiated a new treatment strategy of preoperative radiotherapy for glioblastoma patients. The first patient completed the treatment, and the study is now open for further recruitment. Paired tumor sampling and advanced imaging analysis showed promising results. The POBIG study offers a unique opportunity for a paradigm shift towards personalized treatment regimens, hopefully leading to better outcomes.

Radiotherapy delays malignant transformation and prolongs survival in patients with IDH-mutant gliomas.

IDH-mutant lower-grade gliomas (LGGs, grade 2 or 3) eventually transform into secondary grade 4 astrocytomas (sA_IDHmut/G4). Here, we sought to describe the transformation time, risk factors, and outcomes in malignant transformation of IDH-mutant LGGs. We screened data for 108 patients with sA_IDHmut/G4 in the Chinese Glioma Genome Atlas who had initial IDH-mutant LGGs and underwent reoperation during 2005-2021. We evaluated the transformation time from IDH-mutant LGGs to sA_IDHmut/G4, and associated risk factors and outcomes. Malignant transformation was defined as pathological confirmation of grade 4 astrocytoma. The median age of the 108 patients with IDH-mutant LGGs was 35 years (range, 19-54); the median age at transformation was 40 years (range, 25-62); and the median follow-up time for all patients was 146 months (range, 121-171). The average transformation time was 58.8 months for all patients with LGGs (range, 5.9-208.1); 63.5 and 51.9 months for grade 2 and 3 gliomas, respectively; and 58.4 and 78.1 months for IDH-mutant/1p/19q-non-codeleted astrocytomas and IDH-mutant/1p/19q-codeleted oligodendrogliomas, respectively. Univariate and multivariate analysis indicated that radiotherapy [hazard ratio (HR), 0.29; 95% confidence interval (CI), 0.137-0.595; <i>P</i> = 0.001] and non-A blood type (HR, 0.37; 95% CI, 0.203-0.680; <i>P</i> = 0.001) were protective factors against delayed malignant transformation. Radiotherapy was associated with improved survival after transformation (HR, 0.44; 95% CI, 0.241-0.803; <i>P</i> = 0.008), overall survival (HR, 0.50; 95% CI, 0.265-0.972; <i>P</i> = 0.041), and progression-free survival (HR, 0.25; 95% CI, 0.133-0.479; <i>P</i> &lt; 0.0001) in patients with IDH-mutant gliomas. Radiotherapy is associated with delayed malignant transformation and improved survival in patients with IDH-mutant gliomas.

Association of delayed chemoradiotherapy with elevated Epstein-Barr virus DNA load and adverse clinical outcome in nasopharyngeal carcinoma treatment during the COVID-19 pandemic: a retrospective study

Background:To summarize the impact of radiotherapy (RT) and chemotherapy delays on patients with nasopharyngeal carcinoma (NPC) during the COVID-19 pandemic.Methods:We retrospectively included 233 patients with stage II-IVa NPC treated with RT and chemotherapy between December 11, 2019 and March 11, 2020. The outcomes were elevation in the EBV DNA load between two adjacent cycles of chemotherapy or during RT, and 1-year disease-free survival (DFS).Results:RT delay occurred in 117 (50%) patients, and chemotherapy delay occurred in 220 (94%) patients. RT delay of ≥ 6 days was associated with a higher EBV DNA elevation rate (20.4% vs. 3.6%, odds ratio [OR] = 6.93 [95% CI = 2.49–19.32], P < 0.001), and worse 1-year DFS (91.2% vs. 97.8%, HR = 3.61 [95% CI = 1.37–9.50], P = 0.006), compared with on-schedule RT or delay of < 6 days. Chemotherapy delay of ≥ 10 days was not associated with a higher EBV DNA elevation rate (12.5% vs. 6.8%, OR = 1.94 [95% CI = 0.70–5.40], P = 0.20), or worse 1-year DFS (93.8% vs. 97.1%, HR = 3.73 [95% CI = 0.86–16.14], P = 0.059), compared with delay of < 10 days. Multivariable analyses showed RT delay of ≥ 6 days remained an independent adverse factor for both EBV DNA elevation and DFS.Conclusion:To ensure treatment efficacy for patients with nonmetastatic NPC, initiation of RT should not be delayed by more than 6 days; the effect of chemotherapy delay requires further investigation.

Malignant Cord Compression and Timing of Post-Operative Radiotherapy

<h3>Purpose/Objective(s)</h3> Malignant spinal cord compression (MSCC) warrants prompt intervention that often involves neurosurgical decompression followed by radiation therapy (RT). However, post-surgical management including rehabilitation and time for wound healing can delay initiation of post-operative RT. This study aims to retrospectively review the time to initiation (TTI) of RT after surgical intervention for MSCC and its association with ambulatory status at 3 months post-treatment. We also compare TTI in patients discharged to home versus inpatient rehabilitation or skilled nursing facility. <h3>Materials/Methods</h3> We queried our institutional database for patients with solid malignancies and spinal metastases with Bilsky 2 or 3 MSCC who underwent surgical intervention and post-operative RT between 2015-2021. In patients who were ambulatory peri-operatively, we computed the relative risk of decreased ambulation at 3-month follow up using different TTI cutoff values of 30, 42, and 56 days. P values were generated using a 2-sided Fisher's Exact Test. TTI was also evaluated in all patients who underwent post-operative RT based on their discharge to home, skilled nursing facility, or inpatient rehabilitation. <h3>Results</h3> We found 128 patients with MSCC who underwent surgery. Within this group, 68 were ambulatory peri-operatively, received post-operative RT, and had at least 3 months of follow up. Three-month ambulatory rates for TTI of ≤ 30 vs >30 days, ≤ 42 vs > 42 days, and ≤ 56 vs > 56 days were 86% vs 70% (p=0.218), 85% vs 59% (p=0.032), and 83% vs 50% (p=0.028), respectively. Relative risks for inability to ambulate are shown in Table 1. For all patients who received post-operative RT without wound complications causing delays in RT, TTI based on discharge to home (n=42), skilled nursing facility (n=3), or inpatient rehab (n=26) was 28 days (IQR 19-36.75), 21 days (IQR 15-21), and 37 days (IQR 25.25-52.5), respectively. Nine patients were found to have locally recurrent disease-causing cord compression; two recurred after post-operative RT while seven recurred prior to post-operative RT. <h3>Conclusion</h3> The relative risk of inability to ambulate after surgical resection for MSCC was significantly higher if RT was initiated at >42 days after surgery, and even lower at >56 days after surgery. Patients discharged to inpatient rehab had the longest interval between surgery and RT. Further studies evaluating the optimal timing of post-operative RT and causes for delay are needed.

LINC-23. Factors influencing outcomes of older children with Medulloblastoma over 15 years in Peru, a resource limited setting

BACKGROUND: Medulloblastoma is the most common malignant brain tumor in children. While survival has improved in high-income countries (HIC), the outcomes for patients in low-middle-income countries (LMIC) are unclear. Therefore, we sought to determine the survival of children with Medulloblastoma at the Instituto Nacional de Enfermedades Neoplasicas (INEN) between 1997 and 2013 in Peru. METHODS: Between 1997-2013, data from 103 children older than three years with Medulloblastoma were analyzed. Fourteen patients were excluded. The patients were split into two distinct cohorts, 1997 – 2008 and 2009 – 2013, corresponding with chemotherapy regimen changes. Event-free (EFS) and overall survival (OS) were calculated using the Kaplan-Meier method, while prognostic factors were determined by univariate analysis (log-rank test). RESULTS: Eighty-nine patients were included; median age was 8.1 years (range: 3-13.9 years). The five-year OS was 62% (95% CI: 53 – 74%) while EFS was 57% (95% CI: 48 – 69%). The variables adversely affecting survival were anaplastic histology [compared to desmoplastic; OS: HR=3.4, p=0.03], metastasis [OS: HR=3.5, p=0.01; EFS: HR=4.3, p=0.004], delay in radiation therapy of 31-60 days [compared to ≤30 days; EFS: HR=2.1, p=0.04], and treatment 2009 – 2013 cohort[OS: HR=2.2, p=0.02; EFS: HR=2.0; p=0.03]. CONCLUSIONS: Outcomes for Medulloblastoma at INEN were low compared with HIC. Anaplastic sub-type, metastasis at diagnosis, delay in radiation therapy, and treatment in the period 2009 - 2013 negatively affected the outcomes in our study. Multidisciplinary teamwork, timely delivery of treatment and partnerships with loco-regional groups and colleagues in HIC is likely beneficial.

RARE-27. Treatment and outcomes in atypical choroid plexus papilloma: a single institution experience

BACKGROUND: Atypical choroid plexus papillomas (aCPP) are rare central nervous system (CNS) tumors often occurring in very young children. While surgical resection has been a mainstay of therapy, there is no consensus and limited data on the treatment of relapsed or metastatic tumors. METHODS: Retrospective review of the treatment and outcome of patients diagnosed with aCPP since 2011 was performed. RESULTS: Of the seven patients, 4 were male and 3 were female with a median age of 3 years at diagnosis (range: antenatal to 18 years old). All non-metastatic patients (six) were treated with surgery and all achieved gross total resection. Two patients had diffuse leptomeningeal contrast enhancement on diagnosis MRI that resolved after resection of primary tumor alone. One patient developed local relapse underwent re-resection with a GTR then was treated with 4 cycles of chemotherapy based on CPT-SIOP-2000 protocol (carboplatin, etoposide) and has not had further relapse in 24 months. One patient had metastatic disease at the time of diagnosis. They were treated with adjuvant chemotherapy, which stabilized disease for 36 months until they had progression. Additional four cycles were given and has again stabilized disease now 8 months from completion of that therapy. One non-metastatic patient died of unknown causes 28 months from diagnosis. CONCLUSIONS: Surgical resection remains the standard of care for patients with aCPP. However, chemotherapy based on the SIOP backbone may be useful to reduce the need for or to delay radiation therapy in select patients in the relapsed or metastatic setting.

Combination of nivolumab with chemoradiotherapy for locally advanced cervical cancer: NiCOL phase I trial.

5534 Background: Current management of locally-advanced cervical cancers (LACC) relies on chemoradiotherapy (CRT) and brachytherapy. The causal relation between cervical cancer and human papillomavirus infection, which engenders tumor expression of immunoreactive neo-antigens, together with high PD-L1 expression, warrants consideration of immune checkpoint inhibitors (ICI) in the definitive treatment of this disease. We assessed the safety of concurrent and maintenance nivolumab in addition to CRT in patients with LACC. Methods: This prospective, multi-center, dose-confirmation, phase I clinical trial (NiCOL trial; NCT03298893) evaluated the tolerance profile of concurrent and maintenance nivolumab in addition to CRT (45 Gy in 25 fractions with cisplatin 40mg/m² q1w, followed by a brachytherapy boost to 85 Gy) for stage IB3-IVA cervical cancers. Nivolumab was administered at 240 mg q2w starting on day 1 of CRT and in maintenance after CRT completion for up to 6 months (13 cycles). The primary endpoint was the incidence of dose-limiting toxicities (DLT) within 11 weeks after the initiation of treatment (defining the DLT assessment period), corresponding to the first 6 cycles of nivolumab. DLT were defined as grade ≥3 non-hematological toxicities, grade ≥3 immune-related adverse event (irAE), persistent grade ≥2 irAE for ≥1 week despite optimal supportive care, or ≥1-week radiotherapy delay related to treatment toxicity. Secondary endpoints included overall response rate (ORR), progression-free survival (PFS) and treatment tolerance profile. Results: 16 patients (pts) were recruited between 11/2017 and 07/2020. Median age was 46 years [range: 27-77]. Histological types were squamous cell carcinomas (n = 14) and adenocarcinomas (n = 2). Tumors were staged as FIGO IB3 (n = 2), IIB (n = 8), IIIB (n = 1), IIIC1 (n = 4) and IVA (n = 1); 13 tumors were HPV-positive. Three patients experienced DLT, corresponding to grade 3 hypotension (n = 2) and grade 3 acute kidney injury (n = 1). Following the DLT assessment period, while receiving maintenance nivolumab, one patient developed a grade ≥3 irAE corresponding to a grade 3 diarrhea. Two months after brachytherapy completion, ORR was 93.8% [95%CI: 69.8%-99.8%]. With a median follow-up of 16.6 months, three patients experienced disease control failure (at 3,4 and 5 months); site of disease progression was local for two patients, and simultaneously local and distant for one patient. One-year PFS was 81.2% [95% CI: 64.2%-100%]. Conclusions: Concomitant nivolumab with definitive CRT, followed by maintenance nivolumab, appears to be a safe and feasible therapeutic option for LACC, associated with encouraging PFS rates. Further trials evaluating ICI combined with CRT for LACC are warranted in light of these promising results and of those from recent studies evaluating ICI in the metastatic setting. Clinical trial information: NCT03298893.

Factors influencing outcomes of older children with medulloblastoma over 15 years in Peru, a resource‐limited setting

Medulloblastoma is the most common malignant brain tumor in children. While survival has improved in high-income countries (HIC), the outcomes for patients in low-to-middle-income countries (LMIC) are unclear. Therefore, we sought to determine the survival of children with medulloblastoma at the Instituto Nacional de Enfermedades Neoplasicas (INEN) between 1997 and 2013 in Peru. Between 1997 and 2013, data from 103 children older than 3years with medulloblastoma were analyzed. Fourteen patients were excluded. The patients were split into two distinct cohorts, 1997-2008 and 2009-2013, corresponding with chemotherapy regimen changes. Event-free (EFS) and overall survival (OS) were calculated using the Kaplan-Meier method, whereas prognostic factors were determined by univariate analysis (log-rank test). Eighty-nine patients were included; median age was 8.1years (range: 3-13.9years). The 5-year OS was 62% (95% CI: 53%-74%), while EFS was 57% (95% CI: 48%-69%). The variables adversely affecting survival were anaplastic histology (compared to desmoplastic; OS: HR=3.4, p=.03), metastasis (OS: HR=3.5, p=.01; EFS: HR=4.3, p=.004), delay in radiation therapy of 31-60days (compared to ≤30days; EFS: HR=2.1, p=.04), and treatment 2009-2013 cohort (OS: HR=2.2, p=.02; EFS: HR=2.0, p=.03). Outcomes for medulloblastoma at INEN were low compared with HIC. Anaplastic subtype, metastasis at diagnosis, delay in radiation therapy, and treatment in the period 2009-2013 negatively affected the outcomes in our study. Multidisciplinary teamwork, timely delivery of treatment, and partnerships with loco-regional groups and colleagues in HIC is likely beneficial.

Impact of Radiation Therapy on Outcomes After Spinal Instrumentation for Craniocervical Junction Malignancies.

ObjectiveSpinal reconstruction after resection of invasive craniocervical junction malignancies is fraught with technical and management considerations as well as a paucity of data in the existing literature. In this study, we describe our experience with craniocervical junction malignancies, especially the influence of radiation on the need for revision spinal instrumentation. MethodsWe performed a retrospective chart review of all patients who underwent occipitocervical fixation between 2011 and 2019 at The University of Texas MD Anderson Cancer Center. ResultsTwenty-five patients had primary malignancies and 12 (30%) had metastatic tumors. Thirteen (33%) underwent a staged resection in multiple operations during their hospital stay. Tumor resection was performed in 19 patients (48%), while only stabilization was performed in 21 patients (52%). Nine patients (23%) underwent expanded endoscopic transclival approaches for tumor resection, 10 patients (25%) an extreme lateral approach, and 2 patients (5%) an anterior open approach. Eleven patients underwent early postoperative radiation therapy (within 3 months) and 8 underwent delayed radiation therapy (between 3 months and 1 year in 7 patients). The revision rate was 8%, with a median time to revision surgery of 42 months. The administration and timing of adjuvant radiation therapy relative to surgery had no significant effect on the need for instrumentation revision on log-rank and Cox regression analyses (p < 0.05). ConclusionRevision surgery was needed infrequently in our patients. Postoperative radiation therapy was not associated with hardware failure, indicating that the timing of radiation therapy should be dictated by the diagnosis and can be initiated postoperatively without delay.

Effect of prophylactic gastrostomy on nutritional and clinical outcomes in patients with head and neck cancer.

We aimed to identify which enteral feeding method was most beneficial for patients and compare clinical outcomes, quality of life, and complication rates by assessing patients who underwent prophylactic percutaneous endoscopic gastrostomy (pPEG) tube, reactive percutaneous endoscopic gastrostomy (rPEG) tube or reactive nasogastric tube (rNGT) insertion. Patients with head and neck cancers (HNCs) were enrolled between April 1, 2013 and April 17, 2019 (n = 335; 296 males, 39 females). Data concerning patient characteristics and treatment modalities were extracted from the medical records. Comparisons between enteral feeding methods were made by univariate and multivariate analysis. Overall survival (OS) outcomes were analyzed by the log rank test using the Kaplan-Meier method. A total of 335 patients were included. The median follow-up time was 29.5 months. There were forty-six patients in the pPEG tube group, 23 patients in the rPEG tube group, and 266 patients in the rNGT group. pPEG, increased body-mass index (BMI), and N0-1 category were significantly associated with less weight loss in the multivariate analysis (all P &lt; 0.05). pPEG decreased the rate of radiotherapy delay compared with that of reactive interventions (23.1% vs. 47.1%, P = 0.007). In terms of quality of life, global health status, role functioning, emotional functioning, cognitive functioning, pain, and dyspnea were significantly improved in the pPEG tube group (all P &lt; 0.05). BMI and weight loss were independent prognostic factors for clinical survival outcomes (all P &lt; 0.05). pPEG could improve nutrition outcomes, reduce treatment delay, and maintain quality of life.

Breast cancer patients with delayed radiotherapy during the pandemic process

Aim: In this study; We wanted to examine the changes and delays in radiotherapy of all our breast cancer patients diagnosed with COVID-19&#x0D; Material and Method: Radiotherapy delays of our breast cancer patients who had COVID-19 infection before and during radiotherapy between March 2020 and March 2021 were evaluated retrospectively. &#x0D; Results: Sixteen of a total of 642 breast cancer patients, 472 operated and 165 metastatic, who underwent radiotherapy were diagnosed with COVID-19. All patients were women, ages were between 40 and 77 (mean 54.6). Five patients had a mastectomy, 8 had breast-conserving surgery, and 3 had breast cancer with bone metastases. Different radiotherapy schemes were applied at different treatment duration according to the clinical stage and disease status. The first breast cancer patient with COVID-19 infection was diagnosed on 27 June 2020. Our other patients were diagnosed from June to December (n=15) in 2020. Treatment of patients infected during radiotherapy was interrupted after a mean of 10 fractions (2-24 fractions) and treatment was started after a mean of 25 days (21-44 days). Post-operative patients who could not start treatment because they were SARS-CoV-2 PCR positive were able to start treatment after a mean of 22 days (14-30 days). &#x0D; Conclusion: Radiotherapy could not be started at the recommended times for breast cancer patients infected with COVID-19 during the pandemic and the treatments had to be interrupted. Therefore, more care should be taken in the follow-up of these patients; should be considered as patients at risk for local recurrence and metastasis.

COVID-19 testing trends: pre-radiation and throughout cancer care

Abstract Introduction: Patients presenting for radiation therapy (RT) at a single institution were analysed regarding treatment delays and disparities during the coronavirus disease 2019 (COVID-19) pandemic. Methods: The study was conducted at an urban multidisciplinary cancer centre. In April 2020, the institution’s radiation oncology department implemented universal COVID-19 screening protocols prior to RT initiation. COVID-19 testing information on cancer patients planned for RT from 04/2020 to 01/2021 was reviewed. Trends of other lifetime COVID-19 testing and overall care delays were also studied. Results: Two hundred and fifty-four consecutive cancer patients received RT. Median age was 63 years (range 24–94) and 57·9% (n = 147) were Black. Most (n = 107, 42·1%) patients were insured through Medicare. 42·9% (n = 109) presented with stage IV disease. One (0·4%) asymptomatic patient tested positive for COVID-19 pre-RT. The cohort received 975 lifetime COVID-19 tests (median 3 per patient, range 1–18) resulting in 29 positive test results across 21 patients. Sixteen patients had RT delays. Identifying as Hispanic/Latino was associated with testing positive for COVID-19 (p = 0·015) and RT delay (p = 0·029). Conclusion: Most patients with cancer planned for RT tested negative for COVID-19 and proceeded to RT without delay. However, increased testing burden, delays in diagnostic workup and testing positive for COVID-19 may intensify disparities affecting this urban patient population.