PURPOSE:Select patients with metastatic soft tissue sarcoma (STS) may benefit from more aggressive treatment of their primary tumor. We report on the use of combined modality treatment (CMT) using preoperative radiation therapy (RT) followed by surgery to improve local control. METHODS AND MATERIALS:We retrospectively reviewed the data of 19 patients with metastatic STS consecutively treated at our institution with CMT between 2018 and 2023. All patients received moderately hypofractionated 40.05 Gy in 15 fractions followed by surgery. Patients were selected for CMT based on factors that were likely to predict longer survival despite having metastatic disease such as oligometastatic disease (≤5 lesions) and favorable response to systemic therapy. RESULTS:The median size of the primary tumor was 7.6 cm (IQR, 4.4-12.7 cm). Fourteen patients (74%) received systemic therapy immediately before (n = 10) or after (n = 4) CMT. Seven patients (37%) underwent additional metastasis-directed local therapy following CMT to other sites. Pain reduction after CMT was documented in 89% of patients who presented with pain (n = 8 of 9). Median follow-up was 21 months. Two-year local recurrence-free survival, progression-free/distant recurrence-free survival, and overall/cancer-specific survival were 92%, 29%, and 65%, respectively. One patient (5%) had local recurrence. For patients who were not planned to have adjuvant systemic therapy, median systemic therapy-free survival was 15 months. The rate of wound complications within 120 days of surgery was 16%. No planned adjuvant therapy was delayed because of wound complications; all patients commenced systemic therapy within 3 months of surgery. The rate of late RT toxicities was 26%; there were no grade ≥3 late toxicities. CONCLUSIONS:For properly selected patients with metastatic STS with good performance status and long expected survival, a CMT strategy for the primary tumor with moderately hypofractionated preoperative RT offers favorable local control, low toxicity, and pain mitigation without significant effect on systemic therapy resumption.

Purpose:Abdominopelvic soft-tissue sarcomas (AP-STS) are selectively treated with radiation therapy (RT) followed by surgery. We investigated dosimetric factors predictive of acute and long-term gastrointestinal (GI) toxicities in patients treated with preoperative RT for AP-STS. Methods and Materials:We performed a retrospective cohort study of patients treated for nonmetastatic AP-STS with preoperative RT and surgery from 2005 to 2020. Individual loops of small and large bowel, as well as a "Bowel Bag" space, were autocontoured using a clinically validated deep learning-based approach (nnU-Net) and then manually reviewed. Chi-square or Fisher's exact test was used to assess how bowel dosimetry related to the development of GI toxicities. In particular, the effect on GI toxicity of exceeding bowel constraints as defined in the consensus guidelines was evaluated. Recurrence outcomes were analyzed using the Kaplan-Meier method. Results:We evaluated 76 patients with a median follow-up of 46 months (IQR, 42-50). Approximately half of the tumors were located in the retroperitoneal space (n = 39, 51%). A total of 60 patients (79%) presented with de novo disease, and 21% (n = 16) were recurrent presentations that had not received prior RT. Fourteen patients (18%) had a local recurrence alone, 23 (30%) a distant recurrence alone, and 3 (4%) combined local and distant recurrence. As a result of RT, 23 patients (30%) had acute grade 1 to 2 diarrhea, and 14 (18%) had grade 1 nausea. There were no acute grade 3 toxicities. Six patients (8%) had any long-term RT-related toxicity, including 1 small bowel obstruction. Patients were more likely to have an acute GI toxicity if bowel bag V45>195 cm3 (P = .05). Conclusions:Traditional RT volumetric bowel dose constraints are frequently exceeded, given the large size of AP-STS at presentation and the corresponding large RT volumes. Exceeding the conventional bowel dosimetric constraints should not dissuade the use of RT, but instead signal the need for aggressive prophylactic management of potential toxicities.

Multiple myeloma involving the central nervous system (CNS-MM) has a poor prognosis. This retrospective study evaluated outcomes of 45 patients treated with CNS-directed radiation therapy. Six of these patients had survival ranging from 11.2 to 52.2 months from CNS-MM diagnosis. Thus, aggressive multimodality therapy shows promise in achieving durable CNS control and longer-term survival in a small subset of patients. Background: The prognosis of multiple myeloma involving the central nervous system (CNS-MM) is poor. We report outcomes of CNS-MM treated with CNS-directed radiation therapy (RT). Methods: We retrospectively reviewed patients with CNS-MM treated with CNS-directed RT from 2015 to 2024. CNS-MM was defined as having radiographic leptomeningeal or parenchymal disease, and/or pathologic CSF involvement. Complete response (CR) constituted having no atypical cells in CSF or resolution of radiographic disease. Otherwise, patients were categorized with partial response (PR) based on imaging, or stable disease (SD). The Kaplan-Meier method was used to estimate survival. Results: Of 45 patients with CNS-MM, 28 (62.2%) had high-risk disease. Median overall survival (OS) was 3.7 months (range: 0.4-52.2) postdiagnosis of CNS-MM. Most patients ( n = 22, 48.9%) underwent craniospinal irradiation; 9 received whole brain RT (20%), and the others received focal brain or spine RT. The median dose was 20 Gy (2-30 Gy) in 10 fractions (1-15). Due to death or discharge to hospice before further follow-up of treatment efficacy ( n = 24), only 21 patients (46.7%) were evaluable post-RT with adequate CSF or radiographic follow-up. For these evaluable patients, post-RT CR occurred in 14 patients (66.7%), PR in 5 (23.8%), and SD in 2 (9.5%). For patients with CR after RT, the median OS was 7.3 months (3-52.2) from CNS-MM diagnosis. Focal brain CNS-MM associated with improved OS and likelihood of attaining long-term survival with CNS CR. Conclusion: Aggressive multimodality therapy including RT may induce durable CNS control in a small subset of patients with CNS-MM, a high-risk population.

BackgroundSelect patients with relapsed/refractory aggressive B cell lymphoma may benefit from bridging radiation (bRT) prior to anti-CD19-directed chimeric antigen receptor T cell therapy (CAR-T). Here, we examined patient and treatment factors associated with outcomes and patterns of failure after bRT and CAR-T.MethodsWe retrospectively reviewed adults with diffuse large B-cell lymphoma (DLBCL) who received bRT prior to axicabtagene ciloleucel, tisagenlecleucel, or lisocabtagene maraleucel between 11/2017-4/2023. Clinical/treatment characteristics, response, and toxicity were extracted. Survival was modeled using Kaplan-Meier or Cox regression models for events distributed over time, or binary logistic regression for disease response. Fisher’s Exact Test or Mann-Whitney U methods were used.ResultsOf 51 patients, 25.5% had bulky disease and 64.7% had Stage III/IV disease at the time of RT. Comprehensive bRT alone to all disease sites was delivered to 51% of patients, and 29.4% were additionally bridged with systemic therapy. Median follow-up was 10.3 months (95% CI: 7.7-16.4). Overall response rate (ORR) was 82.4% at 30 days post-CAR-T infusion. Median overall survival (OS) was 22.1 months (6.6-not reached) and the median progression-free survival (PFS) was 7.4 months (5.5-30). OS/PFS were 80% (66-99)/78% (64-87) at 1-year, and 59% (44-71)/54% (40-67) at 2-years, respectively. Comprehensive RT to all sites of disease correlated with improved PFS and OS, p ≤ 0.04. Additionally, ECOG ≥2 and Stage III/IV disease predicted poor OS (p ≤ 0.02). Disease bulk, IPI ≥3, and non-GCB histology were poor predictors for disease-specific survival (DSS), p<0.05. The latter two, as well as bRT dose of ≤30 Gy predicted worse PFS (p<0.05). Among patients with advanced stage disease, comprehensive bRT to all sites of disease (n=10) was not associated with improved OS and PFS compared to focal bRT (n=23), p>0.17. No difference was seen in bridging RT vs. chemoRT. Twenty-six patients developed relapse (50.9%), of which 46% was in-field. Risk of in-field relapse correlated with bulky disease (OR=7, 95% CI: 1.2-41, p=0.03) and lack of response at 30 day post-CAR-T evaluation (OR=16.8, 95% CI: 1.6-176, p=0.02), but not with bRT dose (p=0.27).ConclusionbRT and CART is a good treatment strategy for select patients with aggressive B cell lymphoma. Comprehensive bRT including all sites of disease is associated with improved outcomes.

Purpose: Dermal backflow visualized on near-infrared fluorescence lymphatic imaging (NIRF-LI) signals preclinical lymphedema that precedes the development of volumetrically defined lymphedema. We sought to evaluate whether dermal backflow correlates with patient-reported lymphedema outcomes (PRLO) surveys in breast cancer patients treated with regional nodal irradiation (RNI). Methods and Materials: Patients with breast cancer planned for axillary dissection and RNI prospectively underwent perometry, NIRF-LI, and PRLOs (the Lymphedema Symptom Intensity and Distress Survey [LSIDS] and QuickDASH) at baseline, after surgery, and at 6, 12, and 18 months after radiation. Clinical lymphedema was defined as an arm volume increase >= 5% over baseline. Trends over time were assessed using analysis of variance testing. The association between survey responses and both dermal backflow and lymphedema was assessed using a linear mixed-effects model. Results: Sixty participants completed at least 2 sets of measurements and surveys and were eligible for analysis. Fifty-four percent of patients had cT3-T4 disease, 53% cN3 disease, and 75% had a body mass index >25. Dermal backflow and clinical lymphedema increased from 10% to 85% and from 0% to 40%, respectively, from baseline to 18 months. In the adjusted model, soft tissue sensation, neurologic sensation, and functional LSIDS subscale scores were associated with presence of dermal backflow (all P < .05). Both dermal backflow and lymphedema were associated with QuickDASH score (P < .05). Conclusions: In this high-risk cohort, we found highly prevalent early signs of lymphedema, with increased symptom burden from baseline. Presence of dermal backflow correlated with PRLO measures, highlighting a potential NIRF-LI use to identify patients for early intervention trials after RNI. (c) 2023 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

INTRODUCTION: The objective of this study was to assess differences in long-term sexual and menopausal side effects after uterine cancer treatment among treatment modalities. METHODS AND MATERIALS: This is a cross-sectional study that examined women treated for uterine cancer from 2006-2018. Eligible women included those who underwent a hysterectomy/bilateral salpino-oophorectemy alone (HS), with brachytherapy (BT), or with external beam radiation therapy (EBRT). A noncancer cohort of women who underwent a hysterectomy/BSO for benign indications were also identified (non -CA). To compare outcomes, we utilized a shortened form of the female sexual function index (FSFI) and the menopause survey, which consists of 3 subscales: hot flashes, vaginal symptoms, and urinary symptoms. Demographic, comorbidity, and other treatment variables were collected. Survey totals were compared across cohorts using ANOVA tests and logistic regression. RESULTS: A total of 284 women completed the Menopause Survey (Non -CA 64, HS 60, BT 69, EBRT 91); 116 women reported sexual activity in the last 4 weeks and completed the FSFI (NC 32, HS 21, BT 31, EBRT 32). The mean FSFI score for the entire cohort was 11.4 (SD 4.16), which indicates poor sexual function. There was no significant difference between any cohort in the overall FSFI score ( p = 0.708) or in any of the FSFI subscales (all p > 0.05). On univariate analysis, BT was associated with fewer menopausal hot flashes and vaginal symptoms compared to the non -CA cohort ( p < 0.05), which did not persist on multivariable analysis. CONCLUSION: There was no significant difference in sexual dysfunction or menopausal symptoms in those treated for uterine cancer with or without adjuvant radiation. Most patients reported poor sexual function. (c) 2023 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

BackgroundDiffuse large B-cell lymphoma (DLBCL) involving the gastrointestinal (GI) organs is rare, and real-world outcomes after combined modality therapy (CMT) with systemic therapy (ST) and radiotherapy (RT) are not well-characterized, particularly in the contemporary era. We characterized outcomes in a large cohort of GI-DLBCL patients treated with ST alone or CMT.MethodsPatients with GI-DLBCL treated at a single institution were retrospectively reviewed. Kaplan-Meier and Cox regression models estimated survival. Multivariable analyses were conducted using the Cox proportional hazards model.ResultsOf 204 patients, gastric involvement was most common (63%). Most presented with early-stage disease (61%). All patients received ST and 65 patients (32%) received RT, 88% as part of first-line CMT. Median dose was 36 Gy (IQR 30.6–39.6) in 18 fractions (IQR 17–22). Median follow-up was 46 months. Five-year overall survival (OS) and progression-free survival (PFS) was 88% and 84%, respectively; complete response (CR) rate was 82%. Improved OS associated with low IPI (p=0.001), fewer chemotherapy lines (p<0.001), early stage (p<0.006), and CR (p<0.001). Survival did not differ by RT receipt (p>0.25). Only early stage and CR correlated with improved OS on multivariable analysis. Stomach-directed RT vs. RT to other sites correlated with improved PFS and OS (p<0.04). Patients with early stage DLBCL treated with CMT in the post-rituximab era had equivalent OS vs. ST alone, even with fewer chemotherapy cycles (p<0.02; median of 4 with RT vs. 6 cycles without). Fifty patients had bulky disease (≥7.5 cm), of whom 18 (36%) had early stage disease. Among patients with bulky disease, 5 (10%) developed relapse at the initial site of disease bulk. Four of the 5 patients did not receive consolidative radiation. Among these 4 patients, 3 relapsed only in their initial site of bulky disease. Of 191 patients with luminal GI-DLBCL, n=4 (2.1%) developed perforation; only one received RT. Acute Grade 3 toxicities were reported in 41.2% of patients, and 12 (5.8%) patients had late Grade 3 toxicities, 99% attributed to chemotherapy.ConclusionGI-DLBCL patients have favorable outcomes after CMT with minimal late toxicity. CMT may be offered with abridged systemic regimens with equivalent outcomes. Stomach directed-RT may mitigate relapse risk associated with incomplete disease response or bulky disease.

Purpose: Outcomes for patients undergoing chemoradiation for cervical cancer are dependent on adherence to radiation ther-apy (RT). In other diseases, quality of life (QoL) is associated with treatment adherence, but the association between QoL and RT adherence for patients with cervical cancer remains unclear.Methods and Materials: This prospective study included patients undergoing RT for cervical cancer from 2017 to 2021 at an urban safety net hospital. The Functional Assessment of Cancer Therapy-Cervical Cancer Version 4 was used to assess QoL based on 5 subscales (physical, functional, social and emotional, and cervical-cancer specific). The survey was administered at radiation consult, then weekly during RT and at follow-up. Patient information was abstracted from the medical record. Radia-tion nonadherence was defined as missing & GE;2 days of external beam RT. The Functional Assessment of Cancer Therapy-Cer-vical Cancer Version 4 total and subscale scores were compared between adherent and nonadherent patients. Multivariable logistic regression was performed to control for confounding variables.Results: Ninety-three patients were enrolled, completing 522 surveys. Median age at diagnosis was 46 years (interquartile range, 40-51); 76% of patients were Hispanic, and 12% were Black. Only 30% of patients were nonadherent with RT. A psychi-atric comorbidity (P = .012) and symptomatic presentation (P = .027) were associated with decreased adherence. Baseline total QoL was higher in treatment-adherent than in nonadherent patients (median, 124.86; range, 48-160; 108.9, 46-150; P = .01). Higher baseline functional and physical subscale scores were associated with adherence (P < .05). Change from baseline to low-est score during treatment in the emotional subscale was also associated with patient adherence (P < .05). In multivariable analysis, higher baseline physical score, baseline total score, and change in emotional subscale score were associated with adherence (P < .05).Conclusions: Poor QoL during chemoradiation for cervical cancer is associated with missed treatments. Physician assessment of a patient's well-being while they are undergoing RT is of utmost importance to improve adherence to treatment. & COPY; 2022 Elsevier Inc. All rights reserved.

IntroductionSoft tissue sarcomas (STS) of the head and neck (H&N) are rare malignancies that are challenging to manage. We sought to describe the outcomes of patients treated with curative intent using combined surgery and radiation therapy (RT) for H&N STS.MethodsWe performed a single-institution retrospective review of patients with non-metastatic STS of the H&N who were treated from 1968-2020. The Kaplan-Meier method was used to estimate disease-specific survival (DSS) and local control (LC). Multivariable analyses (MVA) were conducted using Cox proportional hazards model.Results192 pts had a median follow-up of 82 months. Tumors arose in the neck (n=50, 26%), paranasal sinuses (n=36, 19%), or face (n=23, 12%). Most patients were treated with post-operative RT (n=134, 70%). Post-op RT doses were higher (median 60Gy, pre-op 50Gy, p<0.001). Treatment sequence was not associated with LC (pre-op RT 78% (63-88), post-op RT 75% (66-82), p=0.48). On MVA, positive/uncertain margin was the only variable associated with LC (HR 2.54 (1.34-4.82), p=0.004). LC was significant on MVA (HR 4.48 (2.62-7.67), p<0.001) for DSS. Patients who received post-op RT were less likely to experience a major wound complication (MWC) (7.5% vs 22.4%, HR 0.28 (0.11-0.68), p=0.005). There was no difference in the rate of late toxicities between patients who received pre-op or post-op RT.ConclusionsH&N STS continues to have relatively poorer LC than STS of the trunk or extremities. We found LC to be associated with DSS. Timing of RT did not impact oncologic or long-term toxicity outcomes, however pre-op RT did increase the chance of developing a MWC.

PURPOSE:The lungs are the most common site of metastasis for patients with soft tissue sarcoma. SABR is commonly employed to treat lung metastases among select patients with sarcoma with limited disease burden. We sought to evaluate outcomes and patterns of failure among patients with sarcoma treated with SABR for their lung metastases. METHODS AND MATERIALS:We performed a retrospective review of patients treated at a tertiary cancer center between 2006 and 2020. Patient disease status at the time of SABR was categorized as either oligorecurrent or oligoprogressive. The Kaplan-Meier method was used to estimate disease outcomes. Uni- and multivariable analyses were conducted using the Cox proportional hazards model. RESULTS:We identified 70 patients with soft tissue sarcoma treated with SABR to 98 metastatic lung lesions. Local recurrence-free survival after SABR treatment was 83% at 2 years. On univariable analysis, receipt of comprehensive SABR to all sites of pulmonary metastatic disease at the time of treatment was associated with improved progression-free survival (PFS; hazard ratio [HR], 0.51 [0.29-0.88]; P = .02). On multivariable analysis, only having systemic disease controlled at the time of SABR predicted improved PFS (median PFS, 14 vs 4 months; HR, 0.37 [0.20-0.69]; P = .002) and overall survival (median overall survival, 51 vs 14 months; HR, 0.17 [0.08-0.35]; P < .0001). CONCLUSIONS:SABR provides durable long-term local control for sarcoma lung metastases. The most important predictor for improved outcomes was systemic disease control. Careful consideration of these factors should help guide decisions in a multidisciplinary setting to appropriately select the optimal candidates for SABR.

OBJECTIVES:To evaluate patients with clinical (c)T4 prostate cancer (PCa), which represent both a heterogenous and understudied population, who often present with locally advanced disease and obstructive symptoms causing significant morbidity and mortality. We analysed whether receiving definitive local therapy influenced symptomatic and oncological outcomes.METHODS:Retrospective analysis of 154 patients with cT4 PCa treated at a single institution in 1996-2020. Systemic therapy with or without local treatment (surgery, radiotherapy [RT], or both). Uni- and multivariate analyses of associations between clinicopathological features (including obstructive symptoms) and receipt of local therapy on overall survival (OS) and disease control were done with Cox regression.RESULTS:The median follow-up time was 5.9 years. Most patients had adenocarcinoma (88%), Gleason score 9-10 (77%), and median baseline prostate-specific antigen (PSA) of 20 ng/mL; most (54%) had metastatic cT4N0-1M1 disease; 24% regionally advanced cT4N1M0, and 22% localised cT4N0M0. Local therapies were RT (n = 44), surgery (n = 28), or both (n = nine). Local therapy was associated with improved OS (hazard ratio [HR] 0.3, P < 0.001), longer freedom from local recurrence (HR 0.39, P = 0.002), less local progression (HR 0.41, P = 0.02), fewer obstructive symptoms with progression (HR 0.31, P = 0.01), and less death from local disease (HR 0.25, P = 0.002). On multivariate, local therapy was associated with improved survival (HR 0.58, P = 0.02), and metastatic disease (HR 2.93, P < 0.001) or high-risk pathology (HR 2.05, P = 0.03) was associated with worse survival.CONCLUSION:Definitive local therapy for cT4 PCa was associated with improved symptomatic outcomes and survival even among men with metastatic disease. Pending prospective evaluation, these findings support definitive treatment with local therapy for cT4 disease in select cases.

PurposeTo improve segmentation accuracy in head and neck cancer (HNC) radiotherapy treatment planning for the 1.5T hybrid magnetic resonance imaging/linear accelerator (MR-Linac), three-dimensional (3D), T2-weighted, fat-suppressed magnetic resonance imaging sequences were developed and optimized.ApproachAfter initial testing, spectral attenuated inversion recovery (SPAIR) was chosen as the fat suppression technique. Five candidate SPAIR sequences and a nonsuppressed, T2-weighted sequence were acquired for five HNC patients using a 1.5T MR-Linac. MR physicists identified persistent artifacts in two of the SPAIR sequences, so the remaining three SPAIR sequences were further analyzed. The gross primary tumor volume, metastatic lymph nodes, parotid glands, and pterygoid muscles were delineated using five segmentors. A robust image quality analysis platform was developed to objectively score the SPAIR sequences on the basis of qualitative and quantitative metrics.ResultsSequences were analyzed for the signal-to-noise ratio and the contrast-to-noise ratio and compared with fat and muscle, conspicuity, pairwise distance metrics, and segmentor assessments. In this analysis, the nonsuppressed sequence was inferior to each of the SPAIR sequences for the primary tumor, lymph nodes, and parotid glands, but it was superior for the pterygoid muscles. The SPAIR sequence that received the highest combined score among the analysis categories was recommended to Unity MR-Linac users for HNC radiotherapy treatment planning.ConclusionsOur study led to two developments: an optimized, 3D, T2-weighted, fat-suppressed sequence that can be disseminated to Unity MR-Linac users and a robust image quality analysis pathway that can be used to objectively score SPAIR sequences and can be customized and generalized to any image quality optimization protocol. Improved segmentation accuracy with the proposed SPAIR sequence will potentially lead to improved treatment outcomes and reduced toxicity for patients by maximizing the target coverage and minimizing the radiation exposure of organs at risk.

Objectives Uterine cancer is the most common gynecologic malignancy in the United States; however, little is understood of long-term sequelae of adjuvant radiotherapy treatment. The purpose of this study was to compare quality of life (QoL) in patients who have undergone surgery with or without adjuvant radiotherapy for uterine cancer. Materials and Methods This is a cross-sectional cohort study that examined women treated for uterine cancer at a tertiary cancer center from 2006-2018. Participants included those who underwent hysterectomy/bilateral salpino-oophorectemy alone (BSO), with brachytherapy (BT), or with external bean radiation therapy (EBRT). A non-cancer cohort of women who underwent a hysterectomy/BSO for benign indications was also identified (NC). To compare QoL we utilized the FACT-En, a validated 27-question survey used to assess QoL in endometrial cancer patients. The survey consists of 5 well-being subscales: physical, social, emotional, functional, and an endometrial-cancer specific subscale. Responses are on a 5-point Likert scale, with a higher score indicating a better quality of life. Maximum score is 172 for the entire survey. Demographic and other treatment variables were obtained from medical records. Subscales and survey totals were compared across cohorts using ANOVA tests. Results 282 women completed the FACT-En survey (BSO 59, BT 70, EBRT 93, NC 65). Median time from surgery to completion of survey was 6.7 years. Women in the NC cohort were significantly younger at survey completion compared to the other cohorts (mean age 63 [std 8.2] NC, 66 [9.6] HS, 68 [8.4] BT, 67 [10.8] EBRT; p<0.001). Mean total FACT-En score for the entire cohort was 114.2 [22.1]. Overall QoL was significantly different between cohorts, with patients in the EBRT cohort reporting the lowest QoL (mean 139.4 [21.6]), followed by the NC cohort (142.1 [26.5]), BSO cohort (146.1 [20.1]), and the BT cohort reporting highest total score (150.6 [18.2], p=0.006). All subscales were significantly different (all p<0.05) across cohorts aside from social well-being subscale. In the physical domain, the EBRT cohort had the lowest average score (23.3 [5.0]), followed by the NC cohort (25.3 [4.2]), the BT cohort (25.0 [3.8]), with the BSO group reporting the highest scores (25.4 [3.9], p=0.001). The NC cohort reported the lowest scores in the endometrial symptom-specific subscale, with a mean score of 53.3 [10.5]. Among patients who had undergone cancer treatment, the EBRT cohort reported the worst average endometrial-specific QoL (53.5 [8.6]), while again the BT group reported the highest score (57.5 [6.1], p=0.007). Conclusion QoL differences between treatment modalities for uterine cancer remain years after treatment. In women with endometrial cancer who require adjuvant therapy, vaginal brachytherapy does not appear to have any long-term effects of reported QOL.

Objectives: The purpose of this study was to utilize a validated cervical cancer quality of life survey to investigate the relationship between patient-perceived quality of life (QOL) and radiation therapy compliance in a safety-net hospital since noncompliance with scheduled radiation significantly increases local recurrence risk for each day treatment is extended. Methods: This prospective, single-institution study included 94 patients undergoing definitive concurrent chemoradiation for cervical cancer from November 2017 to July 2021. The Functional Assessment of Cancer Therapy - Cervical Cancer Version 4 (FACTCx) was used to assess QOL based on four subscales applicable to a broad population (Physical, Functional, Social/Familial, and Emotional) and one cervical cancer-specific subscale. Higher scores were associated with a higher quality of life. The survey was provided at the initial radiation consult, weekly during external beam radiation therapy, and follow-up appointments. FACT-Cx scores were evaluated over time and compared between compliant and noncompliant patients at baseline and each week of treatment using independent t-test analysis. Patient compliance and other clinical factors were abstracted from chart review. Noncompliance was defined as patient initiating (i.e., not due to weather closure or machine malfunction) and missing at least two radiation treatments. Time to noncompliance was defined as the radiation fraction at which the patient became noncompliant. Results: Twenty-seven of the 94 enrolled patients (28.7%) were non- compliant. Physical QOL of noncompliant patients was significantly impaired compared to compliant patients at baseline (Physical QOL, p=0.007) and at each of the first four weeks of radiation therapy. The functional QOL and cervical QOL scores of noncompliant patients were lower at baseline than compliant patients' scores, and the differences were statistically significant at each of the first four and five weeks, respectively. Differences between social QOL and emotional QOL scores at baseline and at each week of radiation were not statistically significant. The total QOL score of noncompliant patients was significantly lower compared to that of the compliant patients at baseline (Total QOL, p=0.010) and at each of the first five weeks. The median fraction when patients become noncompliant was 10 (IQR: 6-18). Change in QOL from baseline during treatment was not associated with patient-initiated noncompliance. Conclusions: This longitudinal prospective analysis suggests that multiple indicators of QOL, including physical, functional, and cervical well-being, are associated with noncompliance to therapy. The median fraction at which patients become noncompliant also suggests 2-3 weeks of treatment as the highest-risk time frame for patient-initiated noncompliance. Therefore, these results may be used to identify patients at risk of missing treatments and allow their physicians to intervene in a timely manner to improve treatment course and outcome. Objectives: The purpose of this study was to utilize a validated cervical cancer quality of life survey to investigate the relationship between patient-perceived quality of life (QOL) and radiation therapy compliance in a safety-net hospital since noncompliance with scheduled radiation significantly increases local recurrence risk for each day treatment is extended. Methods: This prospective, single-institution study included 94 patients undergoing definitive concurrent chemoradiation for cervical cancer from November 2017 to July 2021. The Functional Assessment of Cancer Therapy - Cervical Cancer Version 4 (FACTCx) was used to assess QOL based on four subscales applicable to a broad population (Physical, Functional, Social/Familial, and Emotional) and one cervical cancer-specific subscale. Higher scores were associated with a higher quality of life. The survey was provided at the initial radiation consult, weekly during external beam radiation therapy, and follow-up appointments. FACT-Cx scores were evaluated over time and compared between compliant and noncompliant patients at baseline and each week of treatment using independent t-test analysis. Patient compliance and other clinical factors were abstracted from chart review. Noncompliance was defined as patient initiating (i.e., not due to weather closure or machine malfunction) and missing at least two radiation treatments. Time to noncompliance was defined as the radiation fraction at which the patient became noncompliant. Results: Twenty-seven of the 94 enrolled patients (28.7%) were non- compliant. Physical QOL of noncompliant patients was significantly impaired compared to compliant patients at baseline (Physical QOL, p=0.007) and at each of the first four weeks of radiation therapy. The functional QOL and cervical QOL scores of noncompliant patients were lower at baseline than compliant patients' scores, and the differences were statistically significant at each of the first four and five weeks, respectively. Differences between social QOL and emotional QOL scores at baseline and at each week of radiation were not statistically significant. The total QOL score of noncompliant patients was significantly lower compared to that of the compliant patients at baseline (Total QOL, p=0.010) and at each of the first five weeks. The median fraction when patients become noncompliant was 10 (IQR: 6-18). Change in QOL from baseline during treatment was not associated with patient-initiated noncompliance. Conclusions: This longitudinal prospective analysis suggests that multiple indicators of QOL, including physical, functional, and cervical well-being, are associated with noncompliance to therapy. The median fraction at which patients become noncompliant also suggests 2-3 weeks of treatment as the highest-risk time frame for patient-initiated noncompliance. Therefore, these results may be used to identify patients at risk of missing treatments and allow their physicians to intervene in a timely manner to improve treatment course and outcome.

AbstractPurposeIn order to improve segmentation accuracy in head and neck cancer (HNC) radiotherapy treatment planning for the 1.5T MR-Linac, 3D fat-suppressed T2-weighted MRI sequences were developed and optimized.MethodsAfter initial testing of fat suppression techniques, SPectral Attenuated Inversion Recovery (SPAIR) was chosen as the fat suppression technique. Five candidate SPAIR sequences and a non-suppressed T2-weighted sequence were acquired on five HNC patients on the Unity MR-Linac. The primary tumor, metastatic lymph nodes, parotid glands, and pterygoid muscles were delineated by five segmentors. A robust image quality analysis platform was developed to objectively score the SPAIR sequences based on a combination of qualitative and quantitative metrics.ResultsSequences were analyzed for signal-to-noise (SNR), contrast-to-noise (CNR) compared to fat and muscle, conspicuity, pairwise distance metrics, segmentor assessment, and MR physicist assessment. From this analysis, the non-suppressed sequence was inferior to each of the SPAIR sequences for the primary tumor, lymph nodes, and parotid glands, but was superior for the pterygoid muscles. Two SPAIR sequences consistently received the highest scores among the analysis categories and are recommended for use to Unity MR-Linac users for HNC radiotherapy treatment planning.ConclusionsTwo deliverables resulted from this study. First, an optimized 3D fat-suppressed T2-weighted sequence was developed that can be disseminated to Unity MR-Linac users. Second, a robust image quality analysis process pathway, used to objectively score the various SPAIR sequences, was developed and can be customized and generalized to any image quality optimization. Improved segmentation accuracy with the proposed SPAIR sequence can potentially lead to improved treatment outcomes and reduced toxicity by maximizing target coverage and minimizing organ-at-risk exposure.

OBJECTIVE:To evaluate the prognostic significance of hematological toxicities during cervical cancer treatment.METHODS:Patients treated for cervical carcinoma with definitive chemoradiation were identified. Toxicities were assessed during weeks 1 to 6 of concurrent external beam radiation and chemotherapy. Outcomes were analyzed using Cox regression analysis.RESULTS:One hundred twenty-one patients with Federation of Gynecology and Obstetrics stage I-III disease were eligible for analysis. Median age at diagnosis was 45 years (interquartile range, 40-52) with median follow-up time of 34 months (95% confidence interval, 30.8-37.2). All patients experienced some grade of hematologic toxicity. The most common grade 3+ toxicities were low absolute lymphocyte count (n=115, 95%), low white blood cell count (n=21, 17%), and anemia (n=11, 9%). The most common grade 4 toxicity was lymphopenia, experienced by 36% of patients (n=44). Grade 4 lymphopenia was associated with reduced overall survival (hazard ratio [HR], 4.5; P=0.005), progression-free survival (HR, 3.4; P=0.001), and local control (HR, 4.1; P=0.047). Anemia grade 3, 4 was also associated with reduced overall survival (HR, 4.1; P=0.014). After controlling for disease and treatment variables, grade 4 lymphopenia remained significantly associated with reduced overall survival (HR, 9.85; P=0.007). The association with grade 4 lymphopenia only remained significant in women of Hispanic ethnicity.CONCLUSION:Severe lymphopenia was associated with reduced overall survival and progression-free survival in Hispanic women undergoing definitive chemoradiation for cervical cancer, but not associated with outcomes in non-Hispanic women.

Objective. Radiation therapy (RT) may improve outcomes for patients with oligometastatic cancer. We sought to determine if there are long-term survivors treated with definitive RT for recurrent or oligometastatic gynecological cancer (ROMGC), and to evaluate the clinical and disease characteristics of these patients. Methods. We performed a landmark analysis in 48 patients with ROMGC who survived for >= 5 years following definitive RT of their metastasis. Patient characteristics were extracted from the medical record. DFS was modeled using the Kaplan-Meier method. Results. This cohort included 20 patients (42%) with ovarian cancer. 16 (33%) with endometrial cancer, 11 (23%) with cervical cancer, and one (2%) with vaginal cancer. The sites of ROMGC were the pelvic (46%), paraaortic (44%), supraclavicular (7%), mediastinal (4%), axillary (4%) lymph nodes and the lung (5.5%). Median total RT dose and fractionation were 62.1 Gy and 2.1 Gy/fraction; one patient was treated with SBRT. 32 patients (67%) received chemoradiation; these patients had higher rates of median DFS than those treated with RT alone (93 vs. 34 months, P - 0.05). At median follow-up of 11.7 years, 11 (23%) patients had progression of disease. 20 (42%) patients had died, 9 (19%) died from non-gynecologic cancer and 8 (17%) from gynecologic cancer (three were unknown). 25 (52%) patients were alive and disease-free (10 initially had endometrial cancer [63% of these patients], eight had cervical cancer [73%], six had ovarian cancer (30%], one had vaginal cancer (100%]). Conclusions. Long-term survival is possible for patients treated with definitive RT for ROMG, however randomized data are needed to identify which patients derive the most benefit. (C) 2021 Elsevier Inc. All rights reserved.