Role Of Adjuvant Radiotherapy Research Articles

Mucosal melanoma of the head and neck: 32‐year experience in a tertiary referral hospital

Primary mucosal melanomas of the head and neck (HNMM), albeit being rare, are rapidly lethal. Here we report the experience of patients with HNMM treated in our institution over a 32-year period. We aim to review our experience in managing HNMM patients over a 32-year period. Retrospective study. Thirty-five patients diagnosed with HNMM from 1978 to 2009 were retrospectively reviewed, with an emphasis on predictors on survival outcome. Twenty-four patients received curative resection, 6 of them followed by adjuvant radiotherapy. Neck dissections were performed in 8 patients. Four patients received radiotherapy as primary treatment. Seven patients were treated conservatively. The overall mean and median survivals were 50 and 26 months, respectively. The median survival of stage I, II, and III diseases in our group of patients were 39, 10, and 16 months, respectively. The 1-year and 5-year overall survival rates were 65.7% and 22.9%, respectively. Age above 60 (p = 0.007), nodal involvement (p = 0.047;) and stage at presentation (p = 0.046) were shown to be associated with worse overall survival. Sites of tumour did not seem to impact on survival. On multivariate analysis, only age (below or above 60) was found to be statistically significant [RR 4.79 (1.65-13.9), p = 0.004]. Oral cavity melanomas are more likely to have nodal involvement at presentation. Prognosis of HNMM remains grave. Current evidence still supports surgery as the best chance of cure. Role of adjuvant radiotherapy is controversial and does not appear to improve overall survival. Similarly, role of neck dissection is ill-defined.

The Role of Adjuvant Radiation Therapy for Stage I Endometrial Cancer: Does Meta-Analysis Reveal the Answer?

annual death rate from uterine cancer is much less than that from ovarian cancer and only modestly higher than that from cervical cancer, suggesting that high-risk endometrial cancer is actually a relatively rare disease (4). In Northern Europe, where most of the randomized trials were conducted, racial and other demographic characteristics differ from those in the United States, and highrisk endometrial cancer may be even less common. For example, in the Netherlands, home of the PORTEC trials, the annual death rate from endometrial cancer is about 3 per 100 000 women, compared with an annual rate of 5 per 100 000 women in the United States (4,5). We know from these data and from numerous clinical-pathologic analyses that uterine cancer has a heterogeneous presentation and that most of the recurrence (and death) risk, particularly for patients with stage I disease, resides in a relatively small subset of patients whose tumors exhibit multiple risk factors. Ideally, clinical trials would focus on these higher-risk patients for whom the margin for improvement is substantial. However, the desire to assure rapid accrual often leads investigators to broaden inclusion criteria. In fact, this has been one of the primary weaknesses of the endometrial cancer trials. Studies have tended to include large numbers of patients with low-grade or minimally invasive cancers—patients whose baseline risk of recurrence may be less than 5% to 10%. For these patients, even relatively minor side effects from radiation therapy (or lymphadenectomy or chemotherapy) will outweigh the most optimistic level of benefit from that treatment. If the proportion of patients with low-grade or minimally invasive cancers in a trial is large, treatment-related morbidity experienced by patients with low-risk tumors can easily obscure real benefits experienced by the smaller number of patients who have a greater margin for improvement. This phenomenon was well described by Kent and Haywood in their discussion of the potential pitfalls of summary statistics (6). The phenomenon is also clearly illustrated in the results of the GOG-99 trial (7). In that trial, subset analysis of a high-intermediate-risk subgroup suggested a fairly large potential benefit that was completely obscured when the entire group of patients, which on average was a relatively low-risk group, was

Influence of Adjuvant Radiation Therapy Dose and Fraction on Overall Survival for Pancreatic Adenocarcinoma

The role of adjuvant radiation therapy (A-RT) for resected pancreatic adenocarcinoma (PAC) continues to evolve and the optimal A-RT fractionation and dose remain unknown. We aim to determine if there is an association between overall survival (OS) and A-RT dose using a large cohort of resected PAC patients obtained from the National Cancer Data Base (NCDB).

Uterine Adenosarcoma and the Role of Radiation Therapy: A Retrospective Study

Adenosarcoma of the uterus is a rare disease; the role of adjuvant radiation therapy (RT) after hysterectomy is not established. Between 1985 and 2011, 36 women presented with uterine adenosarcoma. Median age was 49 years. The majority of cases presented with early stage disease, including IA (61%), IB (22%), or IIA (3%), and grade of disease was 1 (39%), 2 (3%), or 3 (11%), or unspecified (47%). Treatment included hysterectomy (n=34) followed by adjuvant RT (n=12) or observation only (n=24). 2 patients did not receive a hysterectomy because of medical comorbidities; 1 had a polypectomy and 1 had a myomectomy. RT involved vaginal cuff brachytherapy alone (n=9), pelvic radiation (n=2), or both (n=1). Endpoints included disease free survival (DFS) and overall survival (OS). Median follow-up was 49 months. At 5 years, DFS and OS were 94% and 97%, respectively. Only one patient (3%) had recurrence; this patient had distant metastasis to retroperitoneal lymph nodes, liver, and lung while receiving pelvic radiation. This patient had a high-grade uterine adenosarcoma with extensive embryonal rhabdomyosarcomatous differentiation with a 12.5 cm tumor. She recurred above the radiation field. There were no local failures. Factors associated with OS included grade 2-3 histology (p=0.05), while a statistical trend was seen with stage IB/IIA (p=0.08). Adjuvant RT was not associated with DFS or OS. Multivariable analysis was not performed due to the low number of events. The majority of patients with uterine adenosarcoma present with early-stage tumors and have favorable outcomes. Because recurrences tend to be local, certain patients with high risk features can benefit from adjuvant RT. In this cohort of patients, hysterectomy ± adjuvant RT provides 100% local control and is an excellent therapy.

The Role of Adjuvant Radiation in Stage III Endometrial Cancer

The Role of Adjuvant Radiation in Stage III Endometrial Cancer

Radiotherapy in Older Women With Low-Risk Breast Cancer: Why Has Practice Not Changed?

TO THEEDITOR: The editorial 1 regarding the publication by Soulos et al 2 stated that some older women with breast cancer are being clearly overtreated. Most clinicians will agree with this statement. However, the author also indicated that “offering radiation therapy to a woman with a good-prognosis tumor and a life expectancy of less than 5 years does not seem indicated.” 1(p1578) Although this statement represents a publicly shared standard, 3,4 it is not supported by facts. Several studies have evaluated the role of adjuvant radiotherapy, and all indicated a benefit of radiotherapy in reducing locoregional recurrence rates. 5-11 The Toronto Breast Cancer Study indicated that the relapse rate was 1.2% with tamoxifen alone and decreased to 0% when tamoxifen was given with whole-breast irradiation (WBI). There were no significant differences in the distant recurrence rates, questioning the role of tamoxifen alone in controlling systemic disease in this subgroup of patients. 7 The Cancer and Leukemia Group B 9343 trial published in the same issue of New England Journal of Medicine concurred with the results of the Toronto group. In this study, women age 70 years with tumors 2 cm were assigned to tamoxifen either with or without WBI. The locoregional control recurrence rates were lower in the combined WBI-tamoxifen group (1% v 4%; P .001). 6 These results were supported in a later update abstract presented in 2010, where the only significantly different outcome was local recurrence with a difference of 2% in the irradiated group and 9% in those women who did not receive adjuvant radiotherapy. 5 In view of these facts, it is not clear why omitting radiotherapy in older patients with low-risk disease has become a publicly shared standard. Maybe it is because there were no significant differences between the two groups with regard to the rates of mastectomy for local recurrence, distant metastases, or 5-year rates of overall survival. 3,5-7,12 Giordano 1 commented that older women with low-risk breast cancer treated with adjuvant radiotherapy are at risk for unnecessary adverse effects, inconvenience of treatment, and possibly increased personal costs for a treatment unlikely to offer them any benefit. This could also be applied to the endocrine treatment, as both classes of endocrine agents have their own recognized adverse effects and

The effect of local excision and adjuvant radiotherapy for patients with stage I rectal cancer

Objective To evaluate the long-term survival and treatment failure patterns for patients with stage Ⅰ adenocarcinoma in the lower rectum after local excision with or without adjuvant radiotherapy.Methods From Jan.2000 to Dec.2008,Seventy-seven patients with rectal cancer received local excision.Among them,41 received adjuvant radiotherapy.Fifty-four patients were pathologically proven as T1,the other 23 as T2.Patients were classified into low-and high-risk groups according to tumor grade,the length of tumor,surgical margin,circumference ratio of tumor/rectum and T stage.Survival rates and prognostic factors were estimated by Kaplan-Meier method,and comparisons were made by the Logrank test.Results Fourty patients were followed up more than 5 years.The 5-year locoregional recurrence-free survival (LRFS)and overall survival (OS) rates were 83％ and 82％ for the whole group.There were no significant differences in 5-year LRFS and OS rates in low-risk patients between local excision alone and local excision followed by adjuvant radiotherapy ( 86％ ∶ 83％,x2 =0.29,P =0.588 and 100％ ∶ 100％,x2 =1.50,P =0.221 ).In high-risk patients,the 5-year LRFS were similar (80％ ∶ 82％,x2 =0.27,P =0.600),but the OS were significantly different (92％∶ 66％,x2 =4.64,P =0.031 ) between local excision alone and local excision followed by adjuvant radiotherapy.By univariate analysis,large tumor size,positive margin,poor differentiation,tumor located less than 5 cm from anal verge and pT2 stage were poor prognostic factors for OS.The overall relapse rate for the whole group was 29％,and 70％ of them were locoregional relapse.The 5-year OS for patients treated with radical salvage surgery after local relapse was 69％.Conclusions For stage Ⅰ lower-sited rectal cancer,low-risk patients can achieve good result after local excision alone.The role of adjuvant radiotherapy in high-risk patients needs further evaluation.Local relapse is the main cause of failure,and salvage surgery after local relapse can provide long-term survival. Key words: Rectal neoplasms/surgery; Rectal neoplasms/radiotherapy; Prognosis

Adjuvant Radiotherapy for Stage I Endometrial Cancer: An Updated Cochrane Systematic Review and Meta-analysis

The role of adjuvant radiotherapy in stage I endometrial cancer has changed in recent years. This updated Cochrane systematic review aimed to reexamine the efficacy and toxicity of adjuvant radiotherapy vs no treatment in stage I endometrial cancer. We searched various databases including The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and the Specialised Register of the Cochrane Gynaecological Cancer Review Group (CGCRG) for randomized controlled trials that met the predefined inclusion criteria. The primary outcome was overall survival (OS); secondary outcomes were endometrial cancer-specific survival, locoregional recurrence, distant recurrence, and toxicity. Hazard ratios (HRs) were estimated and pooled if possible; otherwise, dichotomous data were extracted. All statistical tests were two-sided. Of the eight included trials, seven trials (3628 women) compared external beam radiotherapy (EBRT) and no EBRT (or vaginal brachytherapy [VBT]), and one trial (645 women) compared VBT and no additional treatment. EBRT statistically significantly reduced locoregional recurrence compared with no EBRT (or VBT alone) (HR = 0.36, 95% confidence Interval [CI] = 0.25 to 0.52; P < .001), but this did not translate into an improvement in OS (HR = 0.99, 95% CI = 0.82 to 1.20; P = .95), endometrial cancer-specific survival (HR = 0.96, 95% CI = 0.72 to 1.28; P = .80), or distant recurrence rates (risk ratio = 1.04, 95% CI = 0.80 to 1.35; P = .77). EBRT was associated with an increased risk of severe acute toxicity, severe late toxicity, and reduced quality of life scores. EBRT reduces the risk of locoregional recurrence but has no statistically significant impact on cancer-related deaths or OS. However, EBRT is associated with clinically and statistically significant morbidity and a reduction in quality of life.

Is There a Role of Postoperative Radiation Therapy in Completely Resected Stage I/II Thymic Epithelial Tumor?

PurposeRetrospective analyses of patients with stage I-II thymic epithelial tumors (TET) who were treated with either surgery alone (S) or surgery plus postoperative radiation therapy (SRT) were conducted to evaluate the role of adjuvant radiation therapy (RT).Materials and MethodsA total of 110 stage I-II TET patients following complete resection were included in this study. Postoperative radiation therapy was recommended for those with aggressive histologic type and/or invasive features according to the surgeons' judgment during the operation. A median dose of 54.0 Gy (range, 44 to 60 Gy) focused on the primary tumor bed was administered to 57 patients (51.8%).ResultsIn all patients, the rates of overall survival, disease-specific survival, and disease-free survival at 10 years were 91.7%, 97.1%, and 95.8%, respectively. No significant differences in disease-specific survival (100% in the S group and 93.5% in the SRT group at 10 years, p=0.12) and disease-free survival (98.1% in the S group and 94.5% in the SRT group at 10 years, p=0.41) were observed between the treatment groups, although a significantly larger number of World Health Organization (WHO)-type B2-C (p<0.001) and Masaoka stage II (p=0.03) tumors were observed in the SRT group than in the S group. No local recurrence was observed in the SRT group. No grade 2 or greater RT-related toxicities were observed in the SRT group.ConclusionExcellent outcomes were achieved in patients with stage I-II TET who underwent complete resection. Considering excellent local control and low morbidity, adjuvant RT may be considered in high risk patients with WHO-type B2-C histology and Masaoka stage II.

Perineural Invasion in the pN0 Neck in OCSCC

Objective: Perineural invasion (PNI) has been defined as an intermediate risk factor in OCSCC; however, its effect in the pathologically N0 (pN0) neck remains unclear. The objective of this study is to understand 1) the effect of PNI in pN0 OCSCC patients on outcomes, and 2) the role of adjuvant radiation (XRT). Method: Retrospective analysis of 90 OCSCC patients treated surgically with pN0 necks after neck dissection at a tertiary care center from 1999-2008. Overall 22% (20/90) were PNI-positive and 40% (36/90) underwent adjuvant XRT. Of those with PNI, 70% (14/20) underwent adjuvant XRT. Primary outcomes were OS, DSS, DFI, and LRC. Results: There were no differences between the PNI-positive and PNI-negative groups for age, gender, smoking or alcohol status, T-class, margin control, or median follow-up. PNI-positive patients had significantly worse DSS, DFI, and LRC than PNI-negative patients ( P = .049, P = .046, and P = .026, respectively), but there was no difference in OS between the 2 groups ( P = .15). Multivariate analysis verified PNI to be associated with worse DFI and LRC ( P = .02 and P = .006, respectively). Amongst PNI-positive patients, those who received adjuvant XRT demonstrated significantly improved DFI and LRC (mean 6.5 years vs 1.7 years; P = .012 and mean 6.7 years vs 1.9 years; P = .047, respectively). There was no improvement in OS or DSS in those receiving adjuvant XRT. Conclusion: Perineural invasion portends a worse DSS, DFI, and LRC in this cohort of patients with pN0 OCSCC. Adjuvant radiation significantly lengthens the DFI and improves LRC. Thus, it should be strongly considered for patients with PNI-positive pN0 OCSCC.

Timing of Surgery and the Role of Adjuvant Radiotherapy in Ewing Sarcoma of the Chest Wall: A Single-institution Experience

Ewing sarcoma (ES) is the most common chest wall malignancy in adolescents. Current therapy incorporates chemotherapy to treat systemic disease and radiotherapy to assist with local control. We sought to evaluate the timing of surgery and role of adjuvant radiotherapy. We reviewed the St. Jude Children's Research Hospital chest wall ES experience from 1979 to 2009. Patient demographics, tumor characteristics, treatment variables, and outcomes were analyzed with respect to timing of surgery and use of adjuvant radiotherapy. Our cohort consisted of 36 patients with chest wall ES; median follow-up was 14.2years, and 15-year estimate of overall survival was 66%. In patients with localized disease, the timing of surgery (up-front vs. delayed) did not impact margin negativity or the use of adjuvant radiotherapy, but it did decrease the extent of chest wall resection. When considering radiotherapy in patients with localized disease, we found that patients who did not receive radiotherapy had smaller tumor size (median 6 vs. 10cm) (p=0.04) and were more likely to have had negative margins (p=0.01) than patients who received adjuvant radiotherapy. One patient in each group developed a locoregional recurrence. The 15-year estimated of overall survival for patients who received adjuvant radiotherapy was 80 versus 100% for those who did not. Delayed surgery decreased the extent of chest wall resection and helped define a patient population with favorable tumor biology. Patients with complete pathologic responses to chemotherapy, and those with tumors <8cm and negative surgical margins may be spared adjuvant radiotherapy without any decrement in overall survival.

Pseudocoarctation of the Aorta Secondary to Aortic Intimal Sarcoma

We describe a case of a 66-year-old woman who presented with upper extremity hypertension and a pseudocoarctation-like picture secondary to an aortic arch intimal sarcoma.

Management of Pediatric Myxopapillary Ependymoma: The Role of Adjuvant Radiation

Myxopapillary ependymoma (MPE) is a rare tumor in children. The primary treatment is gross total resection (GTR), with no clearly defined role for adjuvant radiation therapy (RT). Published reports, however, suggest that children with MPE present with a more aggressive disease course. The goal of this study was to assess the role of adjuvant RT in pediatric patients with MPE. Sixteen patients with MPE seen at Johns Hopkins Hospital (JHH) between November 1984 and December 2010 were retrospectively reviewed. Fifteen of the patients were evaluable with a mean age of 16.8 years (range, 12-21 years). Kaplan-Meier curves and descriptive statistics were used for analysis. All patients received surgery as the initial treatment modality. Surgery consisted of either a GTR or a subtotal resection (STR). The median dose of adjuvant RT was 50.4 Gy (range, 45-54 Gy). All patients receiving RT were treated at the involved site. After a median follow-up of 7.2 years (range, 0.75-26.4 years), all patients were alive with stable disease. Local control at 5 and 10 years was 62.5% and 30%, respectively, for surgery alone versus 100% at both time points for surgery and adjuvant RT. Fifty percent of the patients receiving surgery alone had local failure. All patients receiving STR alone had local failure compared to 33% of patients receiving GTR alone. One patient in the surgery and adjuvant RT group developed a distant site of recurrence 1 year from diagnosis. No late toxicity was reported at last follow-up, and neurologic symptoms either improved or remained stable following surgery with or without RT. Adjuvant RT improved local control compared to surgery alone and should be considered after surgical resection in pediatric patients with MPE.

Occult Nodal Metastasis in Non–Small-Cell Lung Cancer: Implications for the Radiation Oncologist

TO THE EDITOR: We congratulate Rusch et al for performing the well-designed and thought-provoking ACOSOG (American College of Surgeons Oncology Group) Z0040 trial, which was recently reported in Journal of Clinical Oncology. In their study, occult nodal metastasis was detected in 22% of patients with histologic N0 disease and associated with decreased disease-free and overall survival. These findings are consistent with prior reports from other groups. Rusch et al correctly indicate that immunohistochemical evaluation of lymph nodes should be incorporated into future trials of adjuvant chemotherapy. We wish to point out that the presence of occult nodal disease may also have implications in decisions regarding postoperative radiotherapy. After initial treatment with complete surgical resection, National Comprehensive Cancer Network guidelines recommend postoperative radiotherapy for patients with N2 disease but not for patients with N0 to N1 disease. These recommendations are largely based on trials using outdated techniques, nonrandomized comparisons, and retrospective reviews. Further study is required to define optimal treatment algorithms when modern staging procedures, surgical techniques, systemic therapy, and radiotherapy are available. The ongoing Lung ART (Lung Adjuvant Radiotherapy Trial) study is re-examining the role of adjuvant radiotherapy for N2 disease. A recent review of patients with non–small-cell lung cancer with pathologic N1 disease showed that the thorax was the most common site of initial disease progression, especially for patients who received systemic therapy. This suggests that adjuvant radiotherapy may be worth revisiting in the setting of N1 disease as well. An analysis of failure patterns in ACASOG Z0040 would be of great interest. If occult nodal metastasis were associated with increased risk of locoregional failure, it would strengthen the case for studying adjuvant radiotherapy in selected patients. Occult nodal metastasis could theoretically be associated with a subtype of non– small-cell lung cancer that preferentially spreads via regional lymphatics. This is supported by the fact that no association between occult lymph node metastasis and occult bone marrow involvement was detected in ACASOG Z0040. Thus, identification of occult nodal disease might help identify patients who are likely to benefit from postoperative radiotherapy.

Prognosis and patterns of failure after curative pancreaticoduodenectomy for early-stage ampullary adenocarcinomas.

e14728 Background: Ampullary cancer (AC) is a rare malignancy. There is no consensus about the role of adjuvant radiotherapy and chemotherapy, mainly for early-stage tumors. Methods: Between 2007 and 2012 we performed a retrospective analysis of patients with AC that underwent a pancreaticoduodenectomy (PD) with curative intent in our institution. Results: Twenty-four patients underwent (PD), (M:F=13:11), median age was 63 (range35-83), 87% had R0 resection, median of resected lymph-nodes was 8.5 (range 2-30), 29% had positive lymph-nodes, 46% had perineural invasion, 21% had vascular invasion, 29% had lymphatic invasion, 50% had tumors &gt; 2 cm, 54% had moderately differentiated tumors. AJCC stage pathologic grouping was: I=37,5%, II=29%, III=33%; Median follow-up was 27 months, median progression free survival was 29 months and median overall survival was 101 months. Only lymph-node status was independent prognostic factor for disease free survival on multivariate analysis (p=0,045, HR: 7,8). Among patients with early-stage tumors (n=13), only one received adjuvant therapy. The relapse rate was 23% and 50%, for stage I and IIa tumors, respectively. Among the recurrences, 80% of relapses were distant metastasis without local relapse. In patients with stage IIb and III tumors (n=11), 63,6% received adjuvant treatment (57% chemotherapy and 43% radiochemotherapy). The relapse rate was 100% and 75%, respectively, and 66% of these relapses were distant metastasis without local relapse. 75% of patients who had local recurrence had tumors in stage IIb or III. Conclusions: Our study shows a high disease relapse rate in well-operated patients, even in early-stage tumors, with no nodal involvement, mainly with distant disease. The majority of patients who had local relapses had a more advanced stage and systemic relapses associated. This information can help guide decisions on the choice of adjuvant therapy.

Adjuvant radiotherapy after primary surgical resection in patients with adrenocortical carcinoma: Retrospective cohort analysis.

4641 Background: Adrenocortical carcinoma (ACC) is a rare malignancy with high recurrence and mortality rates. The role of adjuvant radiotherapy (RT) to improve outcome remains unclear. Considering the rarity of ACC, we conducted a historical cohort study to ascertain the effect of adjuvant RT on overall survival and recurrence rates. Methods: Patients were selected from the MD Anderson Cancer Center (MDACC) ACC registry (1998- 2011) who had primary tumor resection with no evidence of distant metastasis at the time of initial diagnosis and a minimum follow-up of 6-months. The adjuvant RT group included patients who received adjuvant RT within 3 months of diagnosis. Control group included patients who did not receive RT and matched based on resection margin status and stage at diagnosis. Results: There were no significant differences between the adjuvant RT group (n=15) and comparison group (n =45) in gender distribution, age, tumor size, functional status, and use of adjuvant mitotane therapy. On multivariate Cox proportional hazard model for overall survival, the adjuvant RT group had hazard ratio of 1.981(95% confidence interval [CI] 0.894-4.391, p=0.0922) compared to the control group. The differences in median time to local recurrence, distant recurrence and of recurrence free survival were not significant between the two groups. In subgroup analysis including only the patients whose initial treatments were from outside of MDACC, RT group (n=15) had hazard ratio of overall survival of 1.604 (95% CI 0.712- 3.613, p=0.2543) compared to group without adjuvant RT (n= 32). Median times to local recurrence, distant recurrence, or of recurrence free survival were also not significantly different between the two groups. Conclusions: To our knowledge, this is the largest single institution report about adjuvant RT use in ACC. In our study, RT did not appear to cause a significant difference in overall survival, recurrence rate, or time to recurrence. However, it is still possible that patients offered adjuvant RT and control groups may have been inherently different. Hence, a prospective study is needed to clarify the role of adjuvant RT in patients with resectable ACC.

The Role of Adjuvant Radiation Therapy for Resected Stage III Thymoma: A Population-Based Study

Because of the rarity of the disease and long survival of most patients, the role of adjuvant radiation therapy in patients with surgically resected stage III thymoma is unclear, and few prospective studies are available. The objective was to evaluate the impact of postoperative radiation therapy after resection of stage III thymoma. The Surveillance, Epidemiology, and End Results (SEER) database was queried for all patients with stage III thymoma who underwent surgical therapy and survived more than 30 days after diagnosis. Survival was estimated with the Kaplan-Meier method. The hazard ratio for death was determined using a Cox proportional hazard model. There were 476 patients with stage III thymoma identified who underwent surgical therapy, did not receive preoperative radiotherapy, and had complete SEER records with regard to radiation treatment. Postoperative radiation therapy was given to 322 patients (67.6%). Patients who received postoperative radiation therapy were younger and had a higher rate of debulking surgery than patients who did not. Patients receiving postoperative radiation had a median overall survival of 127 months (95% confidence interval, 100.9 to 153.1) compared with 105 months (95% confidence interval, 76.9 to 133.1) in patients treated with surgery alone (p=0.038). However, in multivariate analysis, postoperative radiation was not a significant factor affecting overall survival. Disease-specific survival was significantly improved in the adjuvant radiation group, and in multivariate analysis, improved outcomes were associated with postoperative radiation (p=0.049). In this large population-based study, most patients with stage III thymoma were treated with adjuvant radiation. Postoperative radiation was associated with improved disease-specific survival, but not improved overall survival.

Adjuvant Radiation Therapy and Survival for Pure Tubular Breast Carcinoma—Experience From the SEER Database

Pure tubular carcinoma of the breast (PTCB) represents a distinct subtype of invasive ductal carcinoma (IDC) that is generally thought to be associated with better prognosis than even low-grade IDC. There has been controversy as to the role of adjuvant radiation therapy (RT) in this population. We hypothesized that adjuvant RT would demonstrate a survival improvement. We queried the Surveillance, Epidemiology and End Results database for the years 1992-2007 to identify patients with pure tubular carcinomas of the breast. Patient demographics, tumor characteristics, and surgical and RT treatments were collected. Survival analysis was performed using the Kaplan-Meier method for univariate comparisons and Cox proportional hazards modeling for multivariate comparisons, stratifying on the basis of age with a cutoff age of 65. A total of 6465 patients were identified: 3624 (56.1%) patients underwent lumpectomy with RT (LUMP+RT), 1525 (23.6%) patients underwent lumpectomy alone (LUMP), 1266 (19.6%) patients received mastectomy alone (MAST), and 50 (0.8%) patients underwent mastectomy with RT (MAST+RT). When we compared the LUMP+RT and LUMP groups directly, those receiving adjuvant RT tended to be younger and were less likely to be hormone receptor-positive. Overall survival was 95% for LUMP+RT and 90% for LUMP patients at 5 years. For those 65 or younger, the absolute overall survival benefit of LUMP+RT over LUMP was 1% at 5 years and 3% at 10 years. On stratified multivariate analysis, adjuvant RT remained a significant predictor in both age groups (P=.003 in age ≤ 65 and P=.04 in age >65 patients). Other significant unfavorable factors were older age and higher T stage (age >65 only). Since sufficiently powered large scale clinical trials are unlikely, we would recommend that adjuvant radiation be considered in PTCB patients age 65 or younger, although consideration of the small absolute survival benefit is important. Adjuvant radiation can be omitted for patients older than 65.

Pancreatic Neuroendocrine Tumors With Involved Surgical Margins: Prognostic Factors and the Role of Adjuvant Radiotherapy

Pancreatic neuroendocrine tumors (pNET) are rare neoplasms associated with poor outcomes without resection, and involved surgical margins are associated with a worse prognosis. The role of adjuvant radiotherapy (RT) in these patients has not been characterized. We retrospectively evaluated 46 consecutive patients with positive or close (<1 mm) margins after pNET resection, treated from 1983 to 2010, 16 of whom received adjuvant RT. Median RT dose was 50.4 Gy in 1.8-Gy fractions; half the patients received concurrent chemotherapy with 5-fluorouracil or capecitabine. No patients received adjuvant chemotherapy. Cox multivariate analysis (MVA) was used to analyze factors associated with overall survival (OS). Median age at diagnosis was 56 years, and 52% of patients were female. Median tumor size was 38 mm, 57% of patients were node-positive, and 11% had a resected solitary liver metastasis. Patients who received RT were more likely to have larger tumors (median, 54 mm vs. 30 mm, respectively, p = 0.002) and node positivity (81% vs. 33%, respectively, p = 0.002) than those not receiving RT. Median follow-up was 39 months. Actuarial 5-year OS was 62% (95% confidence interval [CI], 41%-77%). In the group that did not receive RT, 3 patients (10%) experienced local recurrence (LR) and 5 patients (18%) developed new distant metastases, while in the RT group, 1 patient (6%) experienced LR and 5 patients (38%) developed distant metastases. Of all recurrences, 29% were LR. On MVA, male gender (adjusted hazard ratio [AHR] = 3.81; 95% CI, 1.21-11.92; p = 0.02) and increasing tumor size (AHR = 1.02; 95% CI, 1.01-1.04; p = 0.007) were associated with decreased OS. Long-term survival is common among patients with involved-margin pNET. Despite significantly worse pathologic features among patients receiving adjuvant RT, rates of LR between groups were similar, suggesting that RT might aid local control, and merits further evaluation.

Identifying patients with node-positive prostate cancer who may benefit from adjuvant pelvic radiation following prostatectomy.

195 Background: Three PRTs address the role adjuvant radiotherapy (RT) following radical prostatectomy (RP) in men with locally advanced and/or margin positive prostate cancer (PCa), one of which demonstrated an improvement in overall survival by the addition of early RT. Not addressed in these studies is the role of adjuvant RT in lymph node positive (LN+) PCa. Methods: We reviewed an IRB-approved prospective database at the Cleveland Clinic and identified 84 men with non-metastatic, LN+ PCa treated with RP from 1987-2010. Men receiving neoadjuvant therapy or adjuvant RT were excluded from this analysis. Pelvic failure (PF) was defined as recurrence in the prostate bed or pelvic LN up to the common iliacs. Distant failures (DF) were defined as any LN recurrence beyond the common iliacs, bone, or other solid organ metastases. Kaplan-Meier estimates of pelvic failure (PF), distant failure (DF) and overall survival (OS) were conducted. Results: Median follow-up was 6 years. The median initial PSA was 10.1 ng/mL, 50% had Gleason 7, 12% had Gleason 8, 31% had Gleason 9 disease. The median number of LNs dissected was 11 (range 1-49) and 36% had &gt;1 LN+. Extracapsular extension was present in 90%, seminal vesicle invasion in 66%, and surgical margins positive in 55%. The 6 week post-operative PSA was undetectable (&lt;0.2 ng/ml) in 58%. Overall, 41% received immediate androgen deprivation therapy (ADT), and 45% received delayed ADT after biochemical or clinical failure, while 23% received salvage RT and 22% received chemotherapy. The 10-year OS was 61%. Clinically documented PF and DF occurred in 14% and 24%, respectively. Gleason score was the factor most predictive of PF, DF, and OS. Comparing Gleason score of ≤7 vs. ≥8, the 5-year PF rate was 3% vs. 24% (p=0.006), the 5-year DF rate was 2% vs. 37% (p&lt;0.0001), and 5-year OS was 97% vs. 74% (p&lt;0.0001), respectively. The number of LN+ was not prognostic. Conclusions: Men with Gleason score ≥8 LN+ PCa have a high rate of pelvic recurrence, and pelvic radiation may be worthy of prospective investigation.