Cancer metastasis is a key event in tumor progression associated not only with mortality but also significant morbidity. Metastatic disease can promote end-organ dysfunction and even failure through mass effect compression of various vital organs including the spinal cord. In such cases, prompt medical attention is needed to restore neurological function, relieve pain, and prevent permanent damage. The three therapeutic approaches to managing metastatic spinal cord compression include corticosteroids, surgery, and radiation therapy. Although each may improve patients' symptoms, their combination has yielded the best outcome. In cancer patients with clinical suspicion of spinal cord compression, dexamethasone should be initiated followed by surgical decompression, when possible, and radiation. The latter becomes the preferred treatment in patients with inoperable disease.

e16077 Background: Beginning in 2005 treatment of advanced renal cell carcinoma (RCC) saw a shift from cytokine to targeted therapies. Medication classes introduced in this period included Tyrosine kinase inhibitors, VEGF inhibitors, and mTOR inhibitors. Clinical trials leading to the approval of these medications often excluded non-clear cell histologies. However, retrospective and prospective data have shown there may be a benefit in non-clear cell histology. The aim of this review was to evaluate the impact of targeted therapies on survival with respect to the histologic subtypes. Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients with RCC diagnosed in 2000-2004 and 2007-2011. Only patients with distant disease at presentation were included. 12 month cause specific survival (CSS) was then calculated for histologic subtypes within the respective timeframes. Results: 12,239 patients met the above criteria. 5,776 patients were diagnosed from 2000-2004. The median age at diagnosis was 64. 65% were male. Histologic classification, (% of overall cases), and [12 month CSS] are as follows: Renal cell (64.3%) [28.3%], clear cell (27.1%) [52.5%], sarcomatoid (5.1%) [20.5%], papillary (2.1%) [50.3%], chromophobe (0.7%) [58.1%], collecting duct (0.5%) [21.9%], medullary (0.1%) [12.5%]. From 2007-2011 6,463 patients were diagnosed. The median age was 65. 67% were male. Histologic classification, (% of overall cases), and [12 month CSS] are as follows: Renal cell (47.8%) [28.6%], clear cell (41.1%) [57.7%], sarcomatoid (5.8%) [22.2%], papillary (3.5%) [44.7%], chromophobe (0.7%) [58.3%], collecting duct (0.6%) [20.0%], medullary (0.4%) [15.4%]. The only significant effect on 12 month CSS was for clear cell type: 52.5% (95% CI 49.9 – 54.9%) to 57.7% (95% CI 55.8-59.6%). Conclusions: While studies have shown activity of targeted therapies in non-clear cell histologies, only clear cell histology has seen a statistically significant improvement in CSS in this review. Notably, prognosis with regard to histologic subtype varied greatly and this is likely a reflection of a heterogeneous family of tumors which will require a more individualized approach in the future.

Cutaneous adnexal carcinomas (CAC) are rare neoplasms arising from hair follicles and sebaceous, apocrine, and eccrine glands. While in general prognosis is good, these tumors are thought to be locally aggressive. Due to the rare nature of these tumors, treatment paradigms have been adapted from skin cancer data. Tumors are generally treated with surgery, with some high-risk patients receiving adjuvant radiation. However, the role of radiation remains undefined and practice varies by institution. Here we aim to identify cohorts of patients that may be at higher risk and analyze outcomes. The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients with CAC with skin as the primary site. Patients diagnosed between 1998 and 2010 were included. Patients with known metastatic disease were excluded. Five-year cause-specific survival (CSS) was then calculated for multiple variables, including tumor size, nodal status, subsite, age, sex, race, and grade. Grade was divided into low grade (I and II) and high grade (III and IV). Frequency of radiation use was evaluated with regard to risk factors. A total of 3551 patients who met the above criteria were identified. The median age was 68 years, and 54.4% were male. Ethnicity was as follows: white 81.2%, black 6.1%, other 5.1%, and unknown 7.5%. Median follow-up was not reached. Grade, nodal status, and age were found to have statistically significant (11.4%, 23.0%, 4.6%, P<0.05) impacts on 5-year CSS. Patients with low- and high-grade disease were found to have 5-year CSS of 97.3% and 85.9%. Those who were node negative vs positive at presentation were noted to have 5-year CSS of 97.1% vs 74.1%. Last, patients stratified by age (70 years as cutoff) had 5-year CSS of 97.6% (<70) and 93.0% (≥70). In all, 7% of well-differentiated tumors and 18% of poorly differentiated tumors received radiation. Node-negative and node-positive patients received radiation in 5% and 58% of cases. While overall prognosis is good, we identified variables that were associated with a statistically inferior 5-year CSS. Nodal involvement and high tumor grade were most predictive, as noted in Table 1. Patients with these risk factors may derive benefit from comprehensive postoperative radiation as these tumors tend to be locoregionally aggressive. Despite its potential therapeutic value, our study shows radiation has been underutilized in these high-risk groups. While prospective data is the best way to confirm or refute our findings, it is always a major clinical challenge to conduct such a study in this rare set of tumors. Nevertheless, we need more data on other potential risk factors such as perineural invasion, extracapsular extension, and lymphovascular invasion.

Merkel cell carcinoma (MCC) is a rare neuroendocrine malignancy of the skin with a predilection for aggressive behavior. Previous studies evaluating sentinel lymph node biopsy (SLNB) in MCC have shown positivity rates typically ranging from 22% to 48% in clinically N0 patients. The benefit of SLNB has also been well established in other similarly aggressive tumors, such as melanoma. As a result, sentinel lymph node biopsy (SLNB) is currently recommended for all clinically N0 patients, though its impact remains unclear. The aim of this review was to evaluate for a survival benefit in clinically N0 patients undergoing SLNB. The Surveillance, Epidemiology, and End Results (SEER) database was used to identify patients diagnosed with MCC from 2003 through 2012 with skin as the primary site. Patients up to age 75 years were included, provided they underwent a cancer-directed surgery. Patients with positive lymph nodes or distant disease were excluded. Cause-specific survival was then compared in patients who underwent SLNB as opposed to no pathologic nodal evaluation. A total of 603 patients were identified who met the above criteria. Patients undergoing SLNB had a median age of 65 years with a range of 38-75, 59% were male, and 95% were white. With regard to tumor size: 57% were ≤2 cm, 13% were 2-5 cm, and 30% were >5 cm. In all, 52% of patients received radiation. Patients with no pathologic nodal evaluation had a median age of 68 years with a range of 37-75, 60% were male, and 94% were white. With regard to tumor size, 34% were ≤2 cm, 19% were 2-5 cm, and 47% were >5 cm. A total of 48% of patients received radiation. Patients undergoing SLNB had an improved 5-year CSS of 91.3% (95% CI 86.4-94.5%) compared to the nonpathologic nodal evaluation group, with a 5-year CSS of 72.5% (95% CI 65.4-78.4%). When analyzing tumors ≤2cm, the improved outcome was maintained for SLNB patients vs nonpathologic the nodal evaluation group with a 5-year CSS of 94.70% (95% CI 88.4-97.6) compared to 79.3% (95% CI 66.6-87.6%). A CSS advantage was found for patients undergoing SLNB. This advantage remained significant when stratifying for tumors <2 cm. The reason for this advantage is not fully clear but could be in part from decreased false negatives for nodal staging, therapeutic effect of the SLNB, or a result of more complete care. While prospective data are needed to confirm these findings, the rare nature of these tumors renders this a clinical challenge. Regardless, our current findings support the standard of care of SLNB in clinically N0 patients.

Inflammatory breast cancer (IBC) is an aggressive subtype of breast cancer. The current treatment paradigm is trimodality approach with neoadjuvant chemotherapy, modified radical mastectomy (MRM), and post-mastectomy radiation therapy (PMRT). Advancements in systemic therapy have improved survival increasing the importance of locoregional control. Even with improving outcomes, survival rates remain unsatisfactory prompting the need to identify individuals that may benefit from treatment intensification. We report tumor characteristics, patient demographics, and oncologic outcomes of IBC in the modern era in order to identify subgroups with poor outcomes. We searched the Surveillance, Epidemiology, and End Results (SEER) database for women with breast cancer. This cohort was narrowed to women with non-metastatic [Adjusted AJCC 6th M (1988+) M0] IBC [Adjusted AJCC 6thT (1988+) T4d] with MRM [(1998+) Breast] with or without external beam PMRT. To be included, patients were treated with either ipsilateral MRM with or without reconstruction with the specified race, age, hormone receptor [ER/PR Status], grade, nodal stage [(1988+)], marital, and radiation data. A minimum of 5 years of follow-up was required. We report the actuarial 5-year cause-specific survival. We identified a cohort of 4841 women treated between 1998 and 2007. The median age of diagnosis was 55. The actuarial 5-year CSS for the whole cohort was 56% (95% CI; 54.0-57.2). Black women made up 13% while white women, other races, and unknown represented 81%, 6%, and <1% respectively. Blacks, whites, and other had 5-year CSS of 42% (37.3-46.0), 58% (55.8-59.3), and 59% (51.8-64.9) respectively. Blacks had a statistically significant (SS) lower CSS than the other groups. PMRT (n = 2903) had a SS benefit compared to no RT (n = 1439) with 5-year CSS of 59% (57.3-61.3) and 49% (46.7-52.4) respectively. Women over 70 years of age had a SS lower CSS compared to women between 50-69, but not when compared to ages 20-49. Patients with high-grade histology had a SS lower CSS than intermediate and low-risk patients with CSS of 49% (47-51.8), 68% (64.6-70.8), and 82% (71.6-89.1) respectively. Negative hormone receptor status or being divorced/widowed was also associated with SS worse survival compared to receptor positive disease and being married respectively. Our study confirms that IBC has several tumor factors are associated with worse survival and suggests some patient factors are associated with health disparity. As such, select patients (e.g. black women) may benefit from individualized treatment intensification including additional adjuvant systemic therapy and/or dose escalated PMRT. Select patients may also benefit from more intense post-treatment surveillance and support. Long-term follow-up and prospective data, if feasible, is needed to confirm our findings and conclusions.

Hodgkin’s lymphoma (HL) is a curable form of pediatric cancer. Late effects from treatment are a concern. Radiation therapy (RT) can be associated with toxicity, including secondary malignant neoplasms (SMN). Pediatric protocols have attempted to decrease RT dose or eliminate RT due to toxicity. Here we evaluate characteristics associated with utilization of RT for pediatric HL, their effects on outcomes and development of SMN. The SEER database was queried for patients diagnosed with HL at ages 0-19 years from 1973-2012. Patient factors were assessed in regards to utilization of RT. Cause specific (CSS) and overall survival (OS) were calculated. Observed-to-expected ratios (O/E) were calculated for secondary tumor sites, comparing the development of cancer to incidence rates for the general population. P<0.05 was used to determine significance. 6572 patients were identified. 83.8% of patients were white, 52.4% male, and 54.7% of patients received RT. Use of RT decreased by decade from 71.5% between 1973 and 1979, 62.7% in the 1980s, 52.1% in the 1990s, to 49.9% in patients treated after 2010. The lowest yearly rate was 39.1% in 2012. RT use increased with age; 35% for those under 4, 50.3% from 5-9 years, 55.5% for those 10-19 years. No difference existed in RT use by sex (males 55.2% vs females 54.2%). Black patients (49.3%) were less likely to receive RT compared to whites (52.9%) and others (52.2%). 90% of patients were from metropolitan areas, with no difference in delivery of RT in metropolitan areas (54.8%) vs nonmetropolitan areas (54.4%). 332 SMNs (O/E 5.87) occurred. RT patients developed 240 SMNs (O/E 6.50) compared with 81 SMNs (O/E 4.81) in patients without RT (P<0.05). RT patients had higher rates of salivary gland, digestive, respiratory, soft tissue, breast, and hematologic cancers compared to patients not receiving RT. Females were at higher risk for all SMNs and solid tumors. For the entire cohort, 10 year CSS and OS were significantly improved for those treated with RT (92.7%, 90.6%) compared to those who did not receive RT (90%, 87.3%). By decade, CSS and OS were significantly improved in RT patients in the 1970s and 1980s. OS and CSS were also improved in the RT cohort in the 1990s and 2000s, though not significantly. Six hundred thirteen patients died from cancer, including 451 from HL and 162 from SMNs. The next leading cause of death was diseases of the heart (76). Use of radiation therapy for pediatric Hodgkin’s lymphoma has decreased over time. A benefit to CSS and OS for patients treated with radiation is present regardless of decade of diagnosis. Improved chemotherapy and increased OS in HL has diminished this relative difference to the point it is no longer significant. SMN is the second leading cause of mortality in this cohort and is more common in females treated with RT.

e18075 Background: Inflammatory breast cancer (IBC) is an aggressive breast cancer. The current treatment paradigm is trimodality therapy with neoadjuvant chemotherapy, modified radical mastectomy (MRM), and post-mastectomy radiation therapy (PMRT). Even with improving outcomes from systemic therapy, survival rates remain unsatisfactory prompting the need to identify patients that may benefit from treatment intensification. We hypothesized that oncologic outcomes of IBC differ between black and white women, contributing to possible health disparities. Methods: We searched the SEER database for women with non-metastatic [AJCC 6th (1988+)] IBC. All patients underwent MRM with the specified race, age, ER, PR, grade, nodal stage, and radiation data. Our primary endpoint was actuarial 5-year cause-specific survival (CSS). Results: We identified a cohort of 4841 women treated between 1998 and 2007. Black, white, and other races represented 13%, 81%, and 6% of the cohort respectively. The peak age at diagnosis was between 45-49 years in black women and 50-54 years in white women. The actuarial 5-year CSS for the whole cohort was 56%. Black, white, and other races had CSS of 42%, 58%, and 59% respectively. Black women had a statistically significant lower CSS than white women (Table 1). The CSS difference remained significant when controlling for receptor status, grade, nodal stage, age <70, and whether PMRT was utilized. The ER/PR+ rates in black and white women were 32% and 38% respectively while the ER/PR- rates were 50% and 44%. Black women had higher rates of high-grade disease than white women (79% v. 70%). Conclusions: Our study suggests a health disparity in black women with IBC. As such, select black women with IBC may be candidates for individualized treatment intensification such as additional adjuvant chemotherapy after standard neoadjuvant therapy and/or dose escalation of PMRT. Further prospective data, if feasible, is needed to confirm our findings and conclusions. 5-year actuarial cause-specific survival of inflammatory breast cancer by race. Race n= 5-year CSS (95% CI) All 4841 56% (54.0-57.2) Black 629 41% (37.3-46.0) White 3906 58% (55.8-59.3)

10538 Background: Pediatric Hodgkin’s lymphoma (HL) is a curable pediatric cancer., with newer protocols focusing on limiting long term toxicity. Radiation therapy (RT) has been associated with development of secondary malignancies (SMs). Here we investigate the factors associated with SMs in pediatric HL. Methods: All patients in the SEER database diagnosed with HL at ages 0-19 years from 1973-2012 were assessed for metachronous SMs. Patient and treatment related factors were assessed to determine risk. Observed-to-expected ratios (O/E) were calculated for each tumor site comparing the HL cohorts development of cancer to what would be expected based on incidence rates for the general population. P < 0.05 was used to determine significance. Results: 6572 patients with pediatric HL were identified. Median survival had not been reached at 20 years. 332 SMs (O/E 5.87) were observed. Patients treated with RT developed 240 SMs (O/E 6.50) including 206 solid tumors compared with 81 SMs (O/E 4.81) and 69 solid tumors (O/E 4.92) in patients without RT (p < 0.05). Highest rates of SMs occurred in salivary gland (O/E 27.3), soft tissue (21.87), breast (10.19) and endocrine cancers (8.53). Increased rates of SMs were also observed for digestive, respiratory, female genital, urinary, brain, and hematologic malignancies. RT patients had higher rates of salivary gland, digestive, respiratory, soft tissue, breast, and hematologic cancers compared to patients not receiving RT. By race, blacks were associated with the highest O/E ratio for solid tumors regardless of treatment. Females were at higher risk for all SMs and solid tumors alone compared with males. There was no significant difference between stage and risk of SM.Utilization of RT decreased from a peak of 71% from 1973-1979 to 47% in patients treated after 2010, and fewer total patients developed SMs by decade with time. After death from HL, SM was the second leading cause of mortality in this cohort. Conclusions: Pediatric HL, regardless of treatment, is associated with predisposition to SM. Females, blacks, and RT patients are at highest risk. Identification of additional patient and tumor factors associated with this predisposition to malignancy are needed to optimize treatment and surveillance.

Inflammatory breast cancer (IBC) is an uncommon but aggressive variant. The current treatment paradigm is trimodality therapy with neoadjuvant chemotherapy, modified radical mastectomy (MRM), and post-mastectomy radiation therapy (PMRT). As systemic therapy decreases rates of distant metastatic disease and improves survival, the need for long-term locoregional control has become more essential. We hypothesize select subgroups benefit relatively less from conventional PMRT. We report the benefit of RT on oncologic outcomes of IBC by subgroup to identify patients that may be suitable for individualized treatment intensification. We searched the Surveillance, Epidemiology, and End Results (SEER) database for women with breast cancer. This cohort was narrowed to women with non-metastatic [Adjusted AJCC 6th M (1988+) M0] IBC [Adjusted AJCC 6th T (1988+) T4d] with MRM [(1998+) Breast] with or without external beam PMRT. To be included, patients were treated with either ipsilateral MRM with or without reconstruction with the specified race, age, hormone receptor [ER/PR Status], grade, nodal stage [Adjusted AJCC 6th N (1988+)], and radiation data. Our primary endpoint was actuarial 5-year cause-specific survival (CSS). We identified a cohort of 4841 women treated between 1998 and 2007. The median age of diagnosis was 55. Black and white women comprised 13% and 81% of the cohort respectively. The actuarial 5-year CSS for the whole cohort was 56%. PMRT (n = 2903) was utilized in 67% of patients while 33% received no RT. There was a significant benefit of PMRT compared to no RT with 5-year CSS of 59% and 50% respectively (Table 1). The benefit was not statistically significant (SS) in black women, but was in white women. N0, N1, N2, and N3 patients comprised 12%, 33%, 27%, and 28% of the cohort respectively. Node negative women had no CSS benefit at 5 years, but node positive women had a significant benefit of RT regardless of nodal stage. Low, intermediate, and high-grade tumors made up 2%, 27%, and 71% of the group. PMRT provided a significant CSS benefit in high-grade tumors with a trend in benefit in the intermediate group. Women over 70 years of age had a significantly lower CSS compared to women between 50-69, but not when compared to ages 20-49. A SS benefit of PMRT was seen regardless of age, but the greatest benefit was seen in the 20-49 group (59% v 47%). Our study suggests select subgroups have worse survival and may benefit relatively less from conventional PMRT. As such, select patients may benefit from individualized treatment intensification including dose escalated PMRT and/or additional adjuvant systemic therapy. Further prospective data, if feasible, is needed to confirm our findings and conclusions.Tabled 1Abstract 2099; Table 1.PatientsSubgroupPMRTn=5-year CSS (95% CI)Whole Cohortn/aAll484156% (54.0-57.2)PMRT290359% (57.3-61.3)No143950% (46.7-52.4)RaceBlackPMRT36046% (39.4-51.3)No20235% (27.6-42.1)WhitePMRT236261% (59.0-63.5)No114352% (48.2-54.7) Open table in a new tab

Glioblastoma (GBM) and anaplastic astrocytoma (AA) are rare pediatric malignancies. These tumors are often treated with radiation therapy (RT), which can increase the risk for second malignant neoplasms (SMNs). These tumors can also be associated with genetic predisposition syndromes that increase the risk of secondary malignancy. The risk of second neoplasm in pediatric patients with AA or GBM has not been defined. The SEER database was queried to identify patients under age 19 at diagnosis of glioblastoma (ICD-O-3 9440/3) or anaplastic astrocytoma (ICD-O-3 9401/3). Population demographics were assessed. Cause specific (CSS) and overall survival were calculated. A MP-SIR session was utilized to determine secondary. Observed-to-expected ratios (O/E) were calculated with a 2-month latency period and with a latency period of 5 years to evaluate for early and late SMNs in comparison to incidence ratios for the population as a whole. P<0.05 was used to determine statistical significance. 478 patients with anaplastic astrocytoma and 668 patients with glioblastoma were identified. A majority of patients were white (n=885, 77.2%) and male (n=651, 56.8%). 17.2% of patients were diagnosed before age 5; 58.1% were diagnosed after age 10. 822 patients received surgery. 69.4% of AAs and 74.5% of GBMs were treated with radiation. At 60 months, CSS and OS for AA were 40.8% and 39.0%, and for GBM were 19.6%, and 18.2%. Ninety-three percent of all deaths were attributed to primary cancer. Combined, AA and GBM had significantly increased development of SMN (O/E 10.26) and solid tumors alone (O/E 11.55). Compared to GBM, patients diagnosed with AA had higher incidences of all SMN (O/E 13.44 vs 7.97) and solid tumors (O/E 15.95 vs 8.58). The rates of CNS tumors and bone and joint tumors were all increased for the combined (O/E 56.79 and 63.83), AA (O/E 70.98 and 55.68), and GBM (O/E 40.57 and 74.79) cohorts, respectively. The combined cohort also had significantly elevated rates of leukemia and colon cancer. Patients treated with RT accounted for all of the increase risk of brain tumors, bone and joint tumors, colon cancer, and leukemia, with normal rates experienced in patients who were not treated with RT. With a latency period of 5 years, the risk of SMN (O/E 5.19), solid tumor (O/E 6.26), and brain tumors (O/E 61.17) remained elevated in those treated with RT, with normalized risk in patients not treated with RT. Pediatric patients with AA and GBM are at a higher risk of developing SMNs if treated with RT. Risk is higher in patients with AA, though this could be due to improved survival and more at risk years. As survival improves with novel therapies, SMNs will become more significant in patients with high grade glial tumors.

e16043 Background: Retrospective studies have shown a correlation between mediastinal germ cell tumors (MGCT) and development of AML. Primary treatment for MGCTs is multiagent chemotherapy, which can also be associated with AML. MGCTs have not been associated with increased risk of other solid tumors. Due to the rarity of these tumors, the risk of secondary malignancy and subsequent survival are not fully defined. Methods: The SEER database was queried for mediastinal germ cell tumors by including all patients from 1973-2012 with ICD-O3 codes 9061/3 through 9102/3 and “primary site labeled” variable in SEER codes C38.1-38.3 and C38.8. An MP-SIR session was utilized to determine secondary malignancies in this cohort. Observed-to-expected ratios (O/E) were calculated with no latency period and with a latency period of 5 years to evaluate for early and late cancers. P < 0.05 was used to determine statistical significance. Results: 1113 patients were identified; patients were predominantly male (92%), white (82%), and in their 30s or younger (78%). 76% were non-seminomatous tumors. 29 total secondary malignancies were identified (O/E 2.34), with significant elevations in respiratory (O/E 4.14, n = 6) and hematopoietic cancers (O/E 6.47, n = 9). One case of nodal NHL and 8 cases of AML (O/E 78.47) were identified. All cases of AML were associated with non-seminomatous MGCTs. 5 cases of AML developed within 0-6 months after diagnosis of MGCT (O/E 1206). Two additional cases were diagnosed with a latency period of 6-11 months and 24-35 months. All patients who developed AML died from the disease, with median survival less than 6 months. Risk of developing AML was highest within 5 years of diagnosis (O/E 271), remained elevated between 5-10 years after diagnosis (O/E 54), before normalizing after 10 years. Increased risk of respiratory malignancy was only present in patients treated with radiation (O/E 5.10). Conclusions: Non-seminomatous MGCTs are associated with an increased risk of secondary AML. The highest risk for AML is within 6 months of diagnosis of MGCT. An increased risk of respiratory cancers is also reported in patients who received radiation therapy. Close surveillance for secondary malignancy is needed though prognosis is very poor.

e18520 Background: Survival of a patient is determined by factors related to patient, tumor and treatment. For patient factors in non-small cell lung cancer (NSCLC), it is unclear whether there is a difference in survival between Caucasians and African Americans (AA). This study aimed to study the racial disparity in survival and other patient factors with overall survival (OS) in NSCLC patients. Methods: The study population included patients treated and with data recorded in our Tumor Registry from 2002 to 2013. Age, gender, race, marital status, stage, histology, tumor location, alcohol and smoking history, insurance information and treatments were tested using chi-square test. A Cox proportional hazards model was used to determine differences in OS (SPSS 18.0). Results: A total of 846 consecutive NSCLC patients were included for analysis. 58.8% were Caucasians and 41.2% AA. Under multivariate analysis, gender, marital status, histology, tumor location (upper/lower), alcohol use, stage, chemotherapy and surgery were significantly associated with OS. Median OS was not significantly different between Caucasians and AA (10.3 vs 7.2 months, HR = 0.925, P = 0.359). Median OS between Caucasians and AA patients were 70.1 vs. NR (not reached) (HR = 0.757, P = 0.314), 11.0 vs 15.2 (HR = 1.396, P = 0.057) and 3.5 vs 3.8 (HR = 1.054, P = 0.665), for stage I-II, III, and IV, respectively. In patient treated with chemotherapy alone, Caucasians had longer median survival than that of AA (8.0 vs 3.6 months, P = 0.002), but not significantly different in patients treated with surgery or radiotherapy alone. Interestingly, for stage III patients, Caucasians significantly benefited from concurrent chemoradiotherapy (n = 57, P = 0.031) but not AA (n = 46, P = 0.189). In stage II patients, Caucasian patients had better survival if they had surgery (n = 39, P = 0.040). Conclusions: This study suggests that there are significant racial disparities of survival in patients with NSCLC. Should these result are validated, future treatment needs to be individualized for these patients.

We compared the oncologic treatment outcomes of breast conservation therapy and mastectomy in patients with early-stage male breast cancer. An analysis of 1777 patients demonstrated similar 5-year cause-specific survival, suggesting less-invasive intervention could be an appropriate option for select men with breast cancer. Further prospective studies are needed to confirm our conclusions.Introduction: Male breast cancer (MBC) is a rare disease and lacks data-based treatment guidelines. Most men are currently treated with modified radical mastectomy (MRM) or simple mastectomy (SM). We compared the oncologic treatment outcomes of early-stage MBC to determine whether breast conservation therapy (BCT) is appropriate. Materials and Methods: We searched the Surveillance, Epidemiology, and End Results database for MBC cases. That cohort was narrowed to cases of stage I-II, T1-T2N0 MBC with surgical and radiation therapy (RT) data available. The patients had undergone MRM, SM, or breast conservation surgery (BCS) with or without postoperative RT. We calculated the actuarial 5-year cause-specific survival (CSS). Results: We identified 6263 MBC cases and included 1777 men with stage I or II, T1-T2, node-negative disease, who had the required treatment information available. MRM without RT was the most common treatment (43%). Only 17%. underwent BCS. Of the BCS patients, 46% received adjuvant RT to complete the traditional BCT. No deaths were recorded in the BCT group, regardless of stage, or in the 3 stage I surgical groups if the men had received RT. The actuarial 5-year CSS was 100% in each BCT group. MRM alone resulted in an actuarial 5-year CSS of 97.3% for stage 1% and 91.2% for stage 2. Conclusion: The results from our study suggest that BCT for early-stage MBC yields comparable survival compared with more invasive treatment modalities (ie, MRM or SM alone). This could shift the treatment paradigm to less-invasive interventions and might have the added benefit of increased functional and psychological outcomes. Further prospective studies are needed to confirm our conclusions. (C) 2016 Elsevier Inc. All rights reserved.

Purpose/Objective(s)Significant racial disparity has been reported in prostate cancer including differences in risk, stage distribution, and pattern of care. This study aimed to report our clinical experience in order to examine the difference in overall survival (OS) between Caucasian and African American (AA) patients treated with different modalities, with consideration of other clinical factors.Materials/MethodsThis single-institution retrospective analysis included prostate cancer patients in our tumor registry treated between 2002 and 2012. Age, gender, race, marital status, insurance status, stage, histology, tumor location, alcohol and smoking history, insurance information, and treatment modality were tested for their significance on OS. Cox proportional hazards model was utilized to determine differences in OS with time being 0 at diagnosis and ending with death or end of follow-up. The proportional hazards assumption was tested using Schoenfeld residuals.ResultsA total of 1338 consecutive patients were included in this study; 769 (58%) were AA, the remaining (42%) were Caucasian. Median follow-up was 47 months. Univariate analysis demonstrated age at diagnosis, marital status, heavy alcohol use, smoking status, and stage were significantly associated with OS (P<.05). Race, insurance situation, and family history of cancer were not significant factors. Median survival was not significantly different between Caucasians and AAs (not reached for both groups). Compared with Caucasians, AA patients were more likely to be younger, unmarried, have later-stage disease at diagnosis, and were less likely to have private insurance and to receive surgery. The 5-year OS rates are 86.4% (82.9%-89.9%), 81.7% (95% CI: 78.5%-85.0%), for Caucasians and AAs, respectively. There was no significant difference in survival between these 2 groups for patients treated with surgery and radiation (P>.05). In Caucasians patients, only age and stage were factors significantly associated with OS (both P<.001), while in AA patients, age, smoking status, marriage status, and stage were all significant factors (all P<.001), after adjusting for other factors, such as insurance status.ConclusionThis study suggests no significant difference in OS, but differences in prognostic factors associated with survival between Caucasians and African Americans with prostate cancer. Smoking status and marriage status were not significant factors for survival for Caucasians, but they were significant factors associated with survival for African American patients. Purpose/Objective(s)Significant racial disparity has been reported in prostate cancer including differences in risk, stage distribution, and pattern of care. This study aimed to report our clinical experience in order to examine the difference in overall survival (OS) between Caucasian and African American (AA) patients treated with different modalities, with consideration of other clinical factors. Significant racial disparity has been reported in prostate cancer including differences in risk, stage distribution, and pattern of care. This study aimed to report our clinical experience in order to examine the difference in overall survival (OS) between Caucasian and African American (AA) patients treated with different modalities, with consideration of other clinical factors. Materials/MethodsThis single-institution retrospective analysis included prostate cancer patients in our tumor registry treated between 2002 and 2012. Age, gender, race, marital status, insurance status, stage, histology, tumor location, alcohol and smoking history, insurance information, and treatment modality were tested for their significance on OS. Cox proportional hazards model was utilized to determine differences in OS with time being 0 at diagnosis and ending with death or end of follow-up. The proportional hazards assumption was tested using Schoenfeld residuals. This single-institution retrospective analysis included prostate cancer patients in our tumor registry treated between 2002 and 2012. Age, gender, race, marital status, insurance status, stage, histology, tumor location, alcohol and smoking history, insurance information, and treatment modality were tested for their significance on OS. Cox proportional hazards model was utilized to determine differences in OS with time being 0 at diagnosis and ending with death or end of follow-up. The proportional hazards assumption was tested using Schoenfeld residuals. ResultsA total of 1338 consecutive patients were included in this study; 769 (58%) were AA, the remaining (42%) were Caucasian. Median follow-up was 47 months. Univariate analysis demonstrated age at diagnosis, marital status, heavy alcohol use, smoking status, and stage were significantly associated with OS (P<.05). Race, insurance situation, and family history of cancer were not significant factors. Median survival was not significantly different between Caucasians and AAs (not reached for both groups). Compared with Caucasians, AA patients were more likely to be younger, unmarried, have later-stage disease at diagnosis, and were less likely to have private insurance and to receive surgery. The 5-year OS rates are 86.4% (82.9%-89.9%), 81.7% (95% CI: 78.5%-85.0%), for Caucasians and AAs, respectively. There was no significant difference in survival between these 2 groups for patients treated with surgery and radiation (P>.05). In Caucasians patients, only age and stage were factors significantly associated with OS (both P<.001), while in AA patients, age, smoking status, marriage status, and stage were all significant factors (all P<.001), after adjusting for other factors, such as insurance status. A total of 1338 consecutive patients were included in this study; 769 (58%) were AA, the remaining (42%) were Caucasian. Median follow-up was 47 months. Univariate analysis demonstrated age at diagnosis, marital status, heavy alcohol use, smoking status, and stage were significantly associated with OS (P<.05). Race, insurance situation, and family history of cancer were not significant factors. Median survival was not significantly different between Caucasians and AAs (not reached for both groups). Compared with Caucasians, AA patients were more likely to be younger, unmarried, have later-stage disease at diagnosis, and were less likely to have private insurance and to receive surgery. The 5-year OS rates are 86.4% (82.9%-89.9%), 81.7% (95% CI: 78.5%-85.0%), for Caucasians and AAs, respectively. There was no significant difference in survival between these 2 groups for patients treated with surgery and radiation (P>.05). In Caucasians patients, only age and stage were factors significantly associated with OS (both P<.001), while in AA patients, age, smoking status, marriage status, and stage were all significant factors (all P<.001), after adjusting for other factors, such as insurance status. ConclusionThis study suggests no significant difference in OS, but differences in prognostic factors associated with survival between Caucasians and African Americans with prostate cancer. Smoking status and marriage status were not significant factors for survival for Caucasians, but they were significant factors associated with survival for African American patients. This study suggests no significant difference in OS, but differences in prognostic factors associated with survival between Caucasians and African Americans with prostate cancer. Smoking status and marriage status were not significant factors for survival for Caucasians, but they were significant factors associated with survival for African American patients.

We aimed to study the difference in survival between non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) patients, with consideration of multiple clinical factors. Study population included all patients treated in our center and with data recorded in the Tumor Registry from 2002 to 2014. Age, gender, race, marital status, insurance status, tumor location, clinical stage, histology, alcohol and smoking history, and treatments were tested for their significances. All alive patients had to be followed for at least 12 months to enter the study. Kaplan-Meier analysis and Cox proportional hazards model were used to determine differences in overall survival (OS). All tests were two-sided and p = 0.05 was considered to be significant. A total of 1428 consecutive lung cancer patients were eligible for analysis. Of these, NSCLC, SCLC and patients with unspecified histology accounted for 76.2%, 14.1%, and 9.7%, respectively. Patients with stage I, II, III and IV for NSCLC and SCLC were 197 (18.1%), 76 (7.0%), 295 (27.1%), 520 (47.8%) and 9 (4.5%), 6 (3.0%), 57 (28.4%), 129 (64.1%), respectively. Under multivariate analysis, age, gender, stage, insurance status, chemotherapy, radiation therapy, and surgery were significantly correlated with OS. Of all patients, median OS (95% CI) between NSCLC and SCLC were 9.2 (8.0-10.5) and 10.1 (8.8-11.4) months (p = 0.081). There was no significant difference of OS between NSCLC and SCLC stratified by age, gender, and race. In patients with stage IV disease, there was a significant differences in OS between patients receiving chemotherapy or not for both NSCLC (9.2 vs 2.1 months, HR = 0.40, 95% CI: 0.33-0.48, p < 0.01) and SCLC patients (10.6 vs 1.7 months, HR = 0.38, 95% CI: 0.26-0.56, p < 0.01). Overall, 53.7% of stage IV NSCLC and 51.2% of stage IV SCLC patients received radiation therapy (p = 0.623). In those received radiation, SCLC had significantly longer OS than NSCLC (8.0 vs 3.9 months, p = 0.012). Thoracic radiation therapy increased OS significantly in NSCLC (4.8 vs 2.5 months, HR = 0.83, 95% CI: 0.70-1.00, p = 0.047) but not in SCLC (7.3 vs 8.0 months, HR = 1.20, 95% CI: 0.84-1.73, p = 0.316). This study suggests that there are no significant differences in overall survival between patients with NSCLC and SCLC. Stage IV NSCLC patients may benefit from thoracic radiation therapy. Prospective study is needed to validate these findings.

Stereotactic body radiation therapy (SBRT) has been used for treatment of spinal cord compression. However, the treatment usually starts 1-2 days after simulation due to complicated planning and QA procedures. This work aims to study the feasibility of using a pre-QA’ed universal SBRT plan to treat the first fraction immediately after simulation for a 5-fraction regimen in emergency spine cases. A universal SBRT plan was created using intensity modulated radiation therapy (IMRT) to avoid the spinal cord for a virtual spinal target at T9-T10 level in an average-sized patient. The length of the target is 7 cm and the volume is 167 cm3. Target dose is 6 Gy with 95% dose coverage. The plan was retrospectively applied to 21 spinal SBRT patients (13 T-spine, 7 L-spine, and 1 C-spine) treated in our clinic, without changing any plan parameters except for adjusting the isocenter to spare the cord. Dose was calculated for the real targets and spinal organ at risk (SOAR, could be cord or caudal equine). The average, maximum and minimum of the mean dose to the real target were 5.97, 6.94, and 5.15 Gy, respectively. For SOARs, they were 3.63, 4.88, and 2.75 Gy, respectively. The average, maximum and minimum target coverage by 6 Gy was 53.9%, 90.4%, and 0%, respectively. The 0% happened in two patients with large size. However, the mean target dose still rendered 5.3 and 5.7 Gy, respectively for the 2 patients. The average, maximum and minimum dose to 10% SOAR was 4.77, 6.53, and 3.07 Gy, respectively. The maximum happened in a case with the SOAR tilted extremely. All cases were better than an AP or AP/PA plan. The ratio of mean dose to the cord and the target was 0.61. The ratio of the dose to 10% of cord and mean dose to the target was 0.80. While in PA or AP/PA plans, these ratios are usually 1. In addition, these cases can be planned in the remaining fractions to an ideal dose distribution to compensate the missing dose in the first fraction. Using a universal SBRT plan to treat the first fraction in cord compression may provide a potential safe strategy for urgent SBRT without compromise the tumor coverage and cord sparing. Future study may generate multiple pre-QA’ed plan templates to match each patient for more individualized planning.

Purpose: Volumetric Modulated Arc Therapy (VMAT) usually achieves higher conformity of radiation doses to targets and less delivery time than Intensity Modulated Radiation Therapy (IMRT). We hypothesized that VMAT will increase integral dose (ID) to patients which will decrease the count of white blood count (WBC) lymphocytes, and consequently has a subsequent impact on the immune system. The purpose of this study is to evaluate the ID to patients undergoing IMRT and VMAT for Head and Neck cancers and its impact on the immune system. Methods: As a pilot study, 30 head and neck patients who received 9-fields IMRT or 3-arcs Radip-Arcbased VMAT were included in this study. Ten of these patients who received the VMAT plans were re-planned using IMRT with the same objectives. ID was calculated for all cases. All patients also had a baseline WBC obtained prior to treatment, and 3 sets of labs drawn during the course of radiation treatment. Results: For the 10 re-planned patients, the mean ID was 13.3 Gy/voxel (range 10.2–17.5 Gy/voxel) for the 9-fields IMRT plans, and was 15.9 Gy/voxel (range 12.4-20.9 Gy/voxel) for the 3-Arc VMAT plan (p=0.01). The integral dose was significant correlated with reducing WBC count during RT even when controlling for concurrent chemotherapy (R square =0.56, p=0.008). Conclusion: Although VMAT can deliver higher radiation dose conformality to targets, this benefit is achieved generally at the cost of greater integral doses to normal tissue outside the planning target volume (PTV). Lower WBC counts during RT were associated with higher Integral doses even when controlling for concurrent chemotherapy. This study is ongoing in our Institution to exam the impact of integral doses and WBC on overall survival.

Preclinical and some anecdotal clinical studies have shown that immunotherapy and radiation therapy may have a synergy, and immune-modulation during radiation therapy may play an important role in cancer treatment. The immune system is adversely impacted during radiation therapy due to radiation dose delivered outside the target. We hypothesize that the integral dose (ID) is directly correlated with a decline in the immune system as represented by a decline in the WBC count. The purpose of this study is to investigate the correlation of ID to the white blood cells (WBC) as well as to the radiation therapy techniques, such as Intensity Modulated Radiation Therapy (IMRT) or Volumetric Modulated Arc Therapy (VMAT), As a pilot study, 30 head and neck patients who received IMRT or VMAT were included in this retrospective study. These patients had either 3 arcs of VMAT treatment or 9-fields of IMRT treatment. These patients had a baseline WBC obtained prior to treatment, and 3 sets of labs drawn during the course of radiation treatment. The WBC reduction due to radiation treatment was determined for each patient. The ID was also calculated for each patient. The ID, WBC reduction, and treatment technique (IMRT or VMAT), were compared and analyzed. The Integral dose has significant correlation with reduced WBC count during RT after controlling for concurrent chemotherapy (R square = 0.56, p = 0.008). When comparing the ID from 9-fields IMRT plans for and 3-Arc VMAT, the patients (n = 21) treated with VMAT plan had significantly higher ID compared to patients (n = 9) treated with IMRT plan. The mean ID was 16.4 Gy for VMAT and 13.0 Gy for IMRT with a p-value of 0.006. Lower WBC counts during RT were associated with higher Integral doses even when controlling for concurrent chemotherapy. Although IMRT and VMAT can deliver higher conformity of radiation doses to targets, however, these benefits are achieved generally at the cost of greater integral doses to normal tissue. This study is ongoing in our Institution to exam the impact of integral doses and white cell count on overall survival.

Low total lymphocyte count and lymphocyte to neutrophil ratio have been reported as poor prognostic indicators for multiple cancers at various stages. However, it is unknown whether the baseline complete blood count is associated with overall survival in patients with head and neck malignancies treated with radiation therapy. The objective of this study is to report the correlation that exists between baseline lymphocyte count and overall survival in patients with head and neck cancer treated with radiation based therapy. This is a retrospective analysis of 150 consecutive patients with non-metastatic Stage I-IV head and neck cancer who were treated with radiation therapy from November of 2009 to October of 2013. Pre-treatment complete blood count, demographic, and clinical variables were extracted from medical records and vital status was obtained by using the Social Security Death Index. Variables and outcomes were analyzed. Of the 150 patients reviewed, 104 had baseline complete blood counts (Median age 58, Male 74, Female 30). The median follow-up duration is 17.5 months. We performed 2 sequential analyses of the data. The initial analysis involved the first 82 patients and it was found that higher baseline lymphocyte count was significantly associated with lower mortality (HR: 0.93, p = 0.0443). The subsequent analysis involved 22 additional patients (n = 104). This was consistent with the findings from the initial analysis: i.e. higher baseline total lymphocyte count was associated with increased overall survival (HR 0.57, p = 0.0665). Other variables such as change in lymphocyte count (HR: 6*10-8, p = 0.749), baseline hemoglobin (HR: 0.87, p = 0.355), lymphocyte-to-neutrophil ratio (HR: 0.92, p = 0.306), age, gender, and race were not significantly associated with overall survival. There may be an association between the baseline lymphocyte count and overall survival in patients with head and neck cancers treated with radiation therapy. This result suggests immune function of each patient may be associated with overall survival. A study with larger sample size and longer follow-up is ongoing to validate this finding.

Peripheral blood cell counts have been reported as poor prognostic factors for cancer patients; however, it still remains unknown that whether they are important for patients treated with radiation therapy. We hypothesized that the overall survival (OS) may be associated with peripheral blood cell counts prior, during, and after radiation therapy in patients with non-small cell lung cancer (NSCLC). Patients with NSCLC treated with thoracic radiation, and with at least three peripheral blood tests including baseline (pre-treatment) and during-treatment data were eligible. Clinical factors including age, gender, clinical stage, concurrent chemotherapy, radiation information (total dose and fractions), total white blood cell, neutrophil, lymphocyte, hemoglobin, and platelet were extracted from the electronic medical records. Statistical analysis was conducted. The endpoint of this study is OS which was calculated using Kaplan-Meier method from the start of radiation therapy. Multivariate analysis was performed using Cox regression for the correlation between OS with clinical factors and components of the blood prior radiation as well as changes after radiation therapy. A P value of <.05 was considered statistically significant. A total of 105 consecutive patients treated between 2009 and 2013 were included in this study. The median (95% CI) age was 60 (59-64) years, and 68 (64.8%) patients were male. There were 5, 5, 47, and 48 patients for clinical stage I, II, III and IV, respectively. Twenty (19.0%) patients were treated with concurrent chemotherapy. The medians (95% CI) of radiation dose and fractions were 43.2 (38.9-46.0) Gy and 20 (18-22), respectively. The median duration of follow up was 23.1 months. The median (95% CI) OS was 13.3 (13.9-19.8) months. High baseline white blood cell and neutrophil counts were correlated with poor OS (P<.001; P=.009). Increasing neutrophils during radiation correlated with an improvement in OS (OR = 0.347, P=.037). Other variables such as hemoglobin, lymphocyte counts, and platelet were not significantly associated with OS before or after radiation therapy. High baseline white blood cell and neutrophil counts were related with poor OS in NSCLC patients receiving radiation therapy, possibly as a result of non-specific detrimental inflammatory response. Neutrophil rise after radiation initiation was associated with improved OS, possibly resulting in part from a directed inflammatory to the radiated carcinoma. This data suggests neutrophil may serve as a marker for treatment response. Further study is needed to validate these findings and the underlying mechanism.