PURPOSE:To investigate the benefits and challenges of implementing a medical physics consult program in a small clinic. METHODS AND MATERIALS:A simplified physics direct patient care (SPDPC) protocol was developed based on previously described programs. The program was streamlined to 1 consult with a physicist during a 30-minute time block. Nonemergent patients were offered the program on the day of external beam simulation and, if they indicated interest in 1 of 3 consults (virtual, day of sim, first day of treatment) via an initial survey, they took the short form of the Spielberger State-Trait Anxiety Inventory (STAI-6). At consult, the physicist provided a brief overview of treatment planning and quality assurance, answered questions, and provided a tour of the treatment room (virtual or in-person). Patients repeated the STAI-6, answered 2 emotional check-in and 3 technical satisfaction questions after the consult, and then repeated the STAI-6, 3 technical satisfaction, and 1 overall satisfaction question at the end of treatment (EOT). RESULTS:The SPDPC clinical trial ran for 2 years. Two hundred patients were offered participation and 45% (n = 90) enrolled. Of them, 67% chose a consult in person on their first day of treatment. Seventy-eight patients completed the consult and 65 completed the EOT survey. The anxiety score was (mean ± standard deviation) 32.1 ± 12.8 at baseline, 27.5 ± 12.0 after the medical physics consult, and 26.7 ± 9.0 at the EOT. The change in mean anxiety score from enrollment to after the medical physics consult was statistically significant (P = .0004), and the change from consult to EOT was not significant. The mean technical satisfaction score was evaluated on a 4-point Likert scale. After the medical physics consult, the mean technical satisfaction score was 3.82 ± 0.51 and at EOT 3.92 ± 0.19. There was no statistically significant difference between these 2 time points. CONCLUSIONS:Establishing a new clinical role for medical physicists in a small clinic can be challenging because of staffing resources and time restrictions. A SPDPC protocol allows smaller clinics to provide medical physics consults despite these challenges, while maintaining a similar positive impact to larger programs on the patient and their care experience.

2063 Background: Treatment options are limited for recurrent WHO Grade 3-4 glioma (HGG). Reirradiation (ReRT) is an option, but the ideal treatment regimen and the benefit of concurrent and adjuvant systemic therapy in the recurrent setting remains unclear. Methods: A retrospective review of patients with recurrent HGG treated with reRT was conducted at 12 institutions. Eligible patients were treated with two courses of fractionated RT (>3 fractions) for glioma with the second course being for HGG. To estimate overall and progression free survival times, the Kaplan-Meier method was used. To assess the relationship between survival times and study variables, Cox proportional hazard regression models were used to calculate hazard ratios and the corresponding 95% confidence interval along with the p-value. SAS (version 9.4, Cary, NC, USA) was used for all analyses. P values < 0.05 were assumed to be statistically significant. Results: 482 eligible patients were identified from 1997 to 2023. 235 (54%) had histologic confirmation of glioblastoma at reRT. The median age at reRT was 53.1 years and median KPS was 80. 196 patients (51%) were treated with reRT at their initial recurrence and 122 (30%) had an IDH mutation. The most common reRT dose and number of fractions were 35 Gy and 10 fractions. 192 patients (44%) and 95 (24%) received concurrent (conc) and adjuvant (adj) temozolomide (TMZ) respectively and 116 (27%) and 110 (28%) received conc and adj bevacizumab (BEV) respectively with reRT. Median OS and PFS were 9.8 and 5.3 months. OS (16.6 vs 7.8 months, HR 2.44 p < 0.01) and PFS (8.6 vs 4.6 months, HR 1.85 p < 0.01) were longer in patients with IDH mutations. Receipt of conc and adj TMZ with reRT was associated with improved OS (HR 0.67 p < 0.01 and HR 0.49 p < 0.01 respectively) and PFS (HR 0.66 p <0.01 and HR 0.47 p < 0.01 respectively). Receipt of concBEV with reRT was associated with worse OS (HR 1.66 p < 0.01) but not PFS (HR 1.15 p = 0.28). AdjBEV was not associated with OS or PFS. Concurrent and adjTMZ were associated with improved OS ( p = 0.04 and <0.01) and PFS ( p = 0.01 and <0.01) for IDHwt tumors. In IDHmt tumors, concTMZ was associated with improved OS but not PFS ( p = 0.03 and 0.11), while adjTMZ was associated with improved OS and PFS ( p = 0.05 and <0.01). Symptomatic adverse radiation effects and Grade 3 or greater neurologic toxicity were seen in 107 (25%) and 86 (20%) of patients respectively. Neither conc nor adjBEV nor TMZ were associated with symptomatic ARE. ConcBEV was associated with lower (13% vs 23%, p = 0.03) and concTMZ was associated with higher rates (25% vs 15%, p = 0.01) of Grade 3 or greater neurologic toxicity. Conclusions: The use of concurrent and adjuvant TMZ with reRT are associated with improved OS and PFS in recurrent HGG. OS and PFS are improved with conc and adjTMZ for IDHwt tumors, while there was no PFS benefit to concTMZ in IDHmt tumors. The rate of high grade neurologic toxicity was decreased with the use of concurrent BEV and increased with the use of concTMZ.

Purpose/Objective(s) Reirradiation (reRT) is a treatment option for recurrent high grade glioma (HGG). However, the ideal treatment regimen and patient selection criteria remain unclear. Materials/Methods A retrospective review of patients with recurrent HGG who received fractionated reRT (>3 fractions) was performed at 12 institutions. The Kaplan-Meier Method was used to estimate overall survival (OS). Cox proportional hazards regression models were used to identify factors associated with OS. Toxicity outcomes were assessed using logistic regression. Significance was assumed if p<0.05. SAS (version 9.4, Cary, NC, USA) was used for all analyses. Results 482 eligible patients were identified. 336 (69.7%) had glioblastoma (GBM), with the remainder having Grade 3 gliomas. At reRT, the median age was 53.1 years (IQR 41.7-62.7 years) and the median KPS was 80 (IQR 70-90). 196 patients (51.0%) received reRT for their initial recurrence, 122 (30.0%) had IDH-mutant tumors, and 161 (46.4%) had MGMT methylation. The median dose at reRT was 47 Gy BED10 (IQR 47-53). 192 (44.4%) and 116 (26.9%) received concurrent temozolomide (TMZ) and bevacizumab (BEV), respectively. Median OS was 9.8 months, with a 1 year survival rate of 40.5%. In a multivariate Cox proportional hazards model, dose > 47.25 Gy BED10 (equivalent to 35 Gy in 10 fractions) was associated with improved OS (HR 0.59, p <0.01). Benefits to dose escalation were seen in both IDH-mutant (median OS 21.3 vs 11.3 months, p = 0.01) and IDH-wild type tumors (median OS 10.2 vs 6.5 months, p < 0.01), and in tumors with (median OS 13.3 vs 6.5 months, p < 0.01) and without MGMT methylation (median OS 9.6 vs 6.5 months, p < 0.01). In addition to dose, statistically significant predictors of OS in the multivariate model were glioblastoma histology (HR 1.98, 95% p < 0.01), tumor diameter > 5 cm (HR 1.47, p < 0.01), a window of < 12 months between RT courses (HR 1.88, p < 0.01), and an increasing number of recurrences prior to reRT (HR 1.25, p < 0.01 per recurrence). 107 patients (25.1%) developed Grade 2 or greater adverse radiation effects (ARE), including both pseudoprogression and radionecrosis. On univariate analysis, only one variable showed prognostic significance-patients with T2 FLAIR abnormality intentionally targeted at reRT were less likely to develop Grade 2 or greater ARE (HR 0.41, 95% p < 0.01). Receipt of BEV was not associated with development of Grade 2 or greater ARE (HR 0.67, p = 0.15). Conclusion Doses greater than the BED-equivalent of 35 Gy in 10 fractions are associated with improved survival at reRT for recurrent HGG. This benefit to dose escalation is particularly profound in IDH-mutant tumors and in MGMT-methylated tumors. Increased dose was not associated with an increase in Grade 2 or greater ARE. Factors that can potentially guide optimal patient selection for reRT include histology (non-GBM), a tumor diameter of < 5cm, an interval of at least 12 months between RT courses, and a small number of recurrences.

BACKGROUND Endometrial papillary serous carcinoma (EPSC) is a rare gynecological malignancy that often metastasizes before the presentation of symptoms or diagnosis of the primary disease. The most common locations of metastases for this malignancy are the lungs, liver, and bones. Metastases to the central nervous system (CNS) are rare. Solitary CNS metastases without other anatomical site spread are exceedingly rare. OBSERVATIONS A 65-year-old female with a past medical history of EPSC presented with right-sided weakness, gait instability, and progressive dysarthria. Neurological evaluation revealed right hemiparesis and dysarthria. Head computed tomography showed an ovoid area of hypoattenuation in the left pons. Magnetic resonance imaging confirmed a 2.6-cm pontine lesion. A biopsy revealed histomorphology and immunophenotype consistent with metastasis of previously diagnosed serous carcinoma of the endometrium. LESSONS Gynecological malignancies, in particular EPSC, can metastasize to atypical locations even without evidence of systemic disease. The authors hypothesize that this may be due to hematogenous spread through the Batson venous plexus. https://thejns.org/doi/10.3171/CASE24513

Higher dose of re-RT and use of concurrent TMZ led to improved OS in recurrent HGG patients without an associated increased rate of ARE. Use of BEV decreased the likelihood of Grade 2 or greater ARE in the re-RT setting for these recurrent HGG patients.

OBJECTIVE:To explore whether treatment with multiple Gamma Knife sessions (mGK) resulted in different survival outcomes or cumulative radiation doses compared to single session Gamma Knife (sGK) in patients who have been treated for ≥10 brain metastases (BMs).METHODS:Thirty-five patients with ≥10 BMs treated with Gamma Knife stereotactic radiosurgery (GK SRS) were identified and separated into sGK vs. mGK cohorts. Survival outcomes and dosimetry data were compared between the two groups. Recursive partitioning analysis (RPA) classes were used to further stratify patients.RESULTS:mGK patients survived longer from the first GK treatment (p<0.009). By RPA class, patients with class 1 had a prolonged survival from BM diagnosis than those in classes 2 and 3 (p=0.004). However, survival was not significantly different between the classes from the first GK treatment (p=0.089). Stratified by mGK vs. sGK and RPA classes, sGK patients in RPA class 1 had the longest survival from BM diagnosis but the worst survival from GK treatment. mGK patients in any RPA class had the best survival from the first GK treatment. For patients with RPA class 2+3, mGK was associated with longer survival from both BM diagnosis and first treatment. Statistical but not clinical differences between the mGK vs. sGK groups were observed in the max dose to the targets and cochlea, and the V40Gy whole brain dose.CONCLUSIONS:mGK may be beneficial if GK is initiated early at first BM diagnosis vs. sGK initiated late. Future research is required to confirm these findings and explore additional areas of interest, such as quality-of-life and economic considerations.

Background and objective To examine the relationship between gene expression profile class and tumor thickness reduction as measured by ultrasonography in response to plaque brachytherapy using a single-center, retrospective cohort study. Methods A total of 15 patients with choroidal melanoma who underwent biopsy for gene expression profiling and were treated with plaque brachytherapy from a single institution from 12/8/14 through 12/19/19 were retrospectively reviewed for clinical characteristics and rate of tumor regression. Ultrasonographic B-scan tumor height was recorded just prior to plaque placement and following plaque removal in the patient's chart to assess percent reduction in tumor thickness from baseline. Results A total of 15 patients met inclusion criteria and were analyzed in this study. Minimum follow-up was 6 months after plaque removal. The percent regression in tumor thickness from baseline as measured by ultrasonography was greater for class 2 tumors than for class 1 tumors at 12-month follow up after treatment, and this difference was statistically significant (P = 0.012). There was no statistical significance in reduction at 3 months (P = 0.46) and 9 months (P = 0.10) after plaque brachytherapy. Although not statistically significant, class 2 tumors appeared to regress more rapidly than class 1 tumors in response to radiation. Conclusions In this study, class 2 choroidal melanoma tumors show a more rapid anatomic response to treatment than class 1 tumors at 12 months post plaque brachytherapy.

Purpose: Our purpose was to evaluate the long-term outcomes of patients with vestibular schwannoma (VS) treated with Gamma Knife stereotactic radiosurgery (GKSRS) with modern techniques, with attention to posttreatment tumor growth dynamics, dosimetric predictors, and late toxicities. Methods and Materials: One hundred twelve patients with VS were treated with GKSRS with a median dose of 12.5 Gy to the 50% isodose line treated between 2004 and 2015, with patients followed up to 15 years. Target and organ-at-risk doses were recorded, and tumor diameter/volume, audiologic decline, and trigeminal/facial nerve preservation were tracked from treatment onward. Results: GKSRS yielded local control of 5, 10, and 15 years at 96.9%, 90.0%, and 87.1% respectively. Pseudoprogression was found in 45%, with a novel pattern detected with peak swelling at 31 months. Pseudoprogression was associated with smaller tumor diameter at treatment and fewer treatment isocenters, but not with the development of any toxicity, nor was it predicted by any dosimetric factor. Median time to hearing loss was 3.4 years with actuarial hearing preservation at 2, 5, and 10 years of 66.5%, 43.1%, and 37.6%, with rate of hearing loss correlating with maximum cochlea and modiolus doses. Trigeminal and facial nerve preservation rates were 92.7% and 97.6%, respectively. Increasing maximum tumor dose was associated with facial paresthesia. Conclusions: Modern GKSRS is a safe and effective treatment for VS on long-term follow-up, with high levels of facial and trigeminal nerve preservation. A novel pattern of pseudoprogression has been identified suggesting longer imaging follow-up may be needed before initiating salvage in those without symptomatic progression. Several tumor and dosimetric predictors have been suggested for the development of different toxicities, requiring further evaluation.

e16603 Background: In localized prostate cancer (LPC), evolving therapeutic techniques and patterns of care including the use of active surveillance (AS) are expected to have had a positive effect on quality of life. A longitudinal assessment of changes in disease presentations and patterns of care in LPC correlated to PROMs is required. Methods: All cases of LPC (T1-T4, N0-N1) at a tertiary care institution were identified between 2005 and 2015. Two cohorts (C1: 2005-10, C2: 2010-15) with a minimum of 2-years follow-up, were identified. Demographics, disease characteristics and management strategies were compared across cohorts. To assess PROMs, a one-time questionnaire including EPIC-26 and Clark’s Quality of Life was administered. Domain summary scores were compared across cohorts. Results: 873 patients met criteria [C1: 422, C2: 535]. Demographics were well balanced (p = 0.10): overall 64.1% white, 12.7% AA, 12.7% Asian. D’Amico risk scores increased over time (p = 0.001): fewer low-risk cases [C1: 49.2%, C2: 43.7%], higher intermediate-risk disease [C1: 34.6%, C2: 40.3%], and stable high-risk proportions [C1: 15.7%, C2: 14.9%]. Patterns of care shifted significantly (p = 0.005) with a marked decrease in radiation therapy [C1: 25.7%, C2: 15.4%], unchanged radical prostatectomy rates [C1: 47.9%, C2: 51.0%], a shift to robotic surgery [C1: 23.8%, C2: 90.3%], and an increase in AS [C1: 21.8%, C2: 30.8%], particularly in low-risk disease [C1: 32.4%, C2: 53.5%]. Questionnaire response rate was 45.1%. Using multivariate regression, C2 demonstrated an improvement in bowel function (p = 0.031) but not in urinary, sexual, or psychometric scores. Conclusions: Notwithstanding an increase in AS utilization for low-risk disease, an improvement in bowel function and lack of improvement in urinary/sexual PROMs in LPC across time-cohorts was noted. This may be accounted for by increased presentations of higher-risk disease managed with robotic surgeries at the expense of radiation therapy. Although time-length bias can influence comparisons, given national trends with a similar shift in presentation and care patterns, these PROM correlations are likely generalizable to the U.S. population.

Stereotactic radiosurgery (SRS) is an accepted treatment for refractory trigeminal neuralgia (TN) after SRS but outcomes are variable. Clinical, radiologic, or dosimetric factors predictive of outcomes remain elusive. We hypothesized that pre-second SRS clinical, MRI and dosimetric factors would influence efficacy and toxicity. Medical records from 1/2000 to 8/2017 were queried, identifying 118 patients receiving second SRS. Pre-treatment clinical and MRI data were collected. Statistics software calculated chi-square tests or binary logistic regressions for categorical or continuous variables, respectively. Fifty-nine patients undergoing second SRS had available follow-up (median 18 months [m], range 1.2 – 156.4 m). Median first SRS dose was 85 Gy and second SRS dose was 75 Gy (40 – 75 Gy). Median age was 69 years. Seven had bilateral TN and 6 had multiple sclerosis (MS). Pain recurred after second SRS in 35/59 (59.3%) at a median 12.2 m (no relief – 156 m). With at least 2 years follow-up, 69.2% (18/26) experienced recurrence. Fifty-five (93.2%) achieved BNI pain scale I-III (good pain outcome) at any point, with a median 2 m (range 0 days – 41 m) time to maximum (max) pain relief. At last follow-up, 12 no longer required meds and 36 had pain control +/- meds (BNI I-III). Facial numbness (FN) occurred in 26 (44%), being bothersome for 7 (11.8%). Dysgeusia, paresthesia, masticator weakness (MW) and xerophthalmia were reported in 2 (8.4%), 6 (10.2%), 2 (8.4%) and 6 (10.2%) patients, respectively. MRI report of vessels near the affected nerve (TNe) was associated with max pain relief within 3 m (p=0.048, 16/27 with vs 3/12 without vessel). Reported contact between vessels and the TNe was associated with dysgeusia (p=0.019, 0/40 without and 2/13 with contact) and paresthesia (p=0.022, 2/38 without and 4/11 with contact). A mass described near the TNe was correlated with MW (p<0.001, 1/2 with and 1/53 without a mass) and decreased need for meds at last follow-up (p=0.001, 2/2 with and 7/46 without a mass). No patients with MS developed new FN (p=0.022, 0/6 with MS vs 26/53 other); MS was not associated with other toxicities. Age, time from initial symptoms, and time to max pain relief were not associated with pain recurrence (p=0.730, 0.245 and 0.527). Prolonged pre-initial SRS symptoms were associated with FN (p=0.025). Low repeat dose (< 70 Gy) and cumulative dose (< 130 Gy) were associated with developing MW (p=0.015 2/14 vs 0/40 in high dose) but, contrary to prior reports, not with recurrence, time to pain relief or other toxicities. Most patients undergoing repeat SRS will experience improvement within at least 1 year and achieve pain control with or without meds (BNI I-III). Toxicity rates among this group are acceptable and generally tolerable. Several MRI features are associated with clinically significant toxicities and warrant further investigation.

For the majority of eyes with choroidal melanoma, radiation therapy is the treatment of choice. Local recurrence after radiation therapy can occur, however, and when it does, salvaging the globe with useful vision is atypical.

PURPOSE:No modern randomized trials exist comparing external beam radiotherapy (EBRT) and plaque brachytherapy (BT) for choroidal melanoma, and the optimal treatment modality is currently unknown. This study compares the patterns of care and efficacy of EBRT vs. BT based on data in the Surveillance, Epidemiology, and End Results database. METHODS AND MATERIALS:The Surveillance, Epidemiology, and End Results database was queried for patients aged 20-79 diagnosed with choroidal melanoma from 2004 to 2011, treated with EBRT or BT; included patients were clinically T1-T4, N0, and M0. Overall survival and cause-specific survival curves were calculated by the Kaplan-Meier method. Univariate and multivariate analyses were performed in the survival and patterns-of-care analyses. RESULTS:A total of 1004 cases (380 EBRT and 624 BT) were included in the survival analysis. There was no difference in the 5-year overall survival (83.3% EBRT vs. 82.5% BT, p = 0.69) and 5-year cause-specific survival (88.3% EBRT vs. 88.3% BT, p = 0.92). In the survival analysis, older age and advanced tumor stage were predictors of increased risk of death. In the patterns-of-care analysis, later year of diagnosis and smaller tumor stage were predictors of BT use. CONCLUSIONS:Advanced tumor stage and older age seem to be independent predictors for risk of death from choroidal melanoma. The use of BT favors smaller tumors and later year of diagnosis. There is no difference in survival between those treated with EBRT or BT, and the utilization of BT is increasing.

A recent randomized controlled trial combining TTFields with temozolomide for the adjuvant treatment of GBMs significantly increased both patient OS and PFS (Stupp et al, JAMA 2015). The primary objectives of this study are to determine whether device compliance and duration of treatment led to improved PFS and OS. A secondary objective is to determine what factors contributed to increased compliance and duration of treatment. Temozolomide was given at 150-200mg/m2, five days out of every 28 days with TTFields applied via four plastic arrays containing electrodes > = 18 hour/day. Demographics from the ten patients enrolled into the trial at our institution were collected and analyzed. Our institution accrued 17 patients into the trial, 10 of whom were randomized to receive TTFields. Median PFS and OS in the patients receiving the device were 12 (IQR: 9-36) and 25 (IQR: 16-47) mos, respectively, compared to the estimated control patients in the trial of 4.0 (95% CI: 3.3-5.2) and 15.6 (95% CI: 16.7-25.0) mos, respectively. The correlation coefficient for duration of treatment and PFS was 0.42 (p=0.27) and OS was 0.37(p=0.33). Subject-level median device compliance had a correlation coefficient with PFS and OS of 0.23 (p = 0.55) and 0.38 (p = 0.31), respectively. Extent of resection [GTR (>95%) vs. NTR, STR, and Biopsy] was associated with improved duration of treatment, 21 vs 8 months (p = 0.30), increased PFS, 40.00 vs 9.00 months (p = 0.048) and OS, 50.00 vs 16.00 months (p = 0.048). Increased compliance positively correlated with improved OS; duration of treatment positively correlated with PFS and OS. Extent of resection improved duration of treatment, PFS and OS, suggesting that patients with aggressive resections are the best candidates for treatment with TTFields. These results will need to be verified in a larger data set.

and delivery time (evaluation with Mobius3d) were charted for each plan.Detailed results will be presented at the meeting.VMAT plans with varying dose prescriptions for multiple BM, had comparable dosimetric coverage as static beam plans for regular and more complex shapes, but were obtained with faster delivery time.For irregular and very long/narrow target shapes, VMAT optimization process might be of advantage, probably due to the optimization process during inverse planning.The use of static beams is more demanding, nevertheless can yield comparable efficient dose distribution, though with lower overall monitor units.

PurposeUveal melanoma is the most common primary intra-ocular malignancy in adults with 4.3 new cases per million people in the U.S., and the most common subtype arises from the choroid. Historically, enucleation was the standard of care for choroidal melanoma until the COMS trial in the 1980’s - 90’s which showed no difference in survival between appropriately selected patients treated with enucleation or plaque brachytherapy. Since these publications, plaque brachytherapy, and more recently, external beam (including particle therapy) have been used to treat non-metastatic choroidal melanoma. Since there are no large, modern randomized trials comparing these therapies, the optimal treatment modality is unknown.Materials and MethodsWe compared the efficacy of EBRT (external beam radiation therapy, e.g., proton beam, gamma knife radiosurgery, etc.) versus RI (radioactive implant, e.g., plaque brachytherapy, etc.) by searching the Surveillance Epidemiology and End Results (SEER) database for men and women aged 20-79 diagnosed with choroidal melanoma (no microscopic confirmation necessary) from 2004-2011, treated with EBRT or RI. Included patients were clinically T1-T4, N0, M0 (AJCC 6th edition, 2004+). Patients who received other types of radiation or more than one radiation modality were excluded. Patients who received surgery as upfront therapy were also excluded. Overall survival (OS) and cause specific survival (CSS) curves were calculated by the Kaplan-Meier method and univariate and multivariate analyses on covariates were calculated by the log-rank test and Cox proportional hazards ratio model. Chi-squared analysis was performed on categorical variables to test their interaction with radiation technique.ResultsA total of 1001 cases (379 EBRT and 622 RI) in the CSS analysis and 1004 cases (380 EBRT and 624 RI) in the OS were analyzed. Most patients had T2 tumors, received RI and were of white race; there was a nearly even split between men and women. In the OS analysis, there were 41 deaths in the EBRT cohort and 65 deaths in the RI cohort. Using the Kaplan-Meier method and the log-rank test, we found no difference between CSS (5 year CSS 88.3% EBRT vs. 88.3% RI p = 0.920) and OS (5 year OS 83.3% EBRT vs. 82.5% RI p = 0.688). Examining each tumor stage subgroup individually (T1-T4) we found no statistically significant difference in OS or CSS in each group, however, there was a trend towards improved OS with EBRT for T1 tumors (5 yr OS 94.9% EBRT vs. 86.6% RI p = 0.08). We analyzed each covariate (radiation type, sex, histology, tumor stage, age at diagnosis, race and year of diagnosis) and found that tumor stage (p=0.001) and age at diagnosis (p = 0.001) were significant on univariate analysis by the log rank test. Using the Cox proportional hazards ratio model, we analyzed these significant covariates and found that both age (p<0.001) HR(Hazard Ratio)=1.044 [1.026-1.062] and tumor stage (p=0.001) T2 HR=1.648 [.989-2.745], T3 HR 2.845 [1.462-5.534], T4 HR 5.739 [2.141-15.382] remained statistically significant on multivariate analysis.Conclusions PurposeUveal melanoma is the most common primary intra-ocular malignancy in adults with 4.3 new cases per million people in the U.S., and the most common subtype arises from the choroid. Historically, enucleation was the standard of care for choroidal melanoma until the COMS trial in the 1980’s - 90’s which showed no difference in survival between appropriately selected patients treated with enucleation or plaque brachytherapy. Since these publications, plaque brachytherapy, and more recently, external beam (including particle therapy) have been used to treat non-metastatic choroidal melanoma. Since there are no large, modern randomized trials comparing these therapies, the optimal treatment modality is unknown. Uveal melanoma is the most common primary intra-ocular malignancy in adults with 4.3 new cases per million people in the U.S., and the most common subtype arises from the choroid. Historically, enucleation was the standard of care for choroidal melanoma until the COMS trial in the 1980’s - 90’s which showed no difference in survival between appropriately selected patients treated with enucleation or plaque brachytherapy. Since these publications, plaque brachytherapy, and more recently, external beam (including particle therapy) have been used to treat non-metastatic choroidal melanoma. Since there are no large, modern randomized trials comparing these therapies, the optimal treatment modality is unknown. Materials and MethodsWe compared the efficacy of EBRT (external beam radiation therapy, e.g., proton beam, gamma knife radiosurgery, etc.) versus RI (radioactive implant, e.g., plaque brachytherapy, etc.) by searching the Surveillance Epidemiology and End Results (SEER) database for men and women aged 20-79 diagnosed with choroidal melanoma (no microscopic confirmation necessary) from 2004-2011, treated with EBRT or RI. Included patients were clinically T1-T4, N0, M0 (AJCC 6th edition, 2004+). Patients who received other types of radiation or more than one radiation modality were excluded. Patients who received surgery as upfront therapy were also excluded. Overall survival (OS) and cause specific survival (CSS) curves were calculated by the Kaplan-Meier method and univariate and multivariate analyses on covariates were calculated by the log-rank test and Cox proportional hazards ratio model. Chi-squared analysis was performed on categorical variables to test their interaction with radiation technique. We compared the efficacy of EBRT (external beam radiation therapy, e.g., proton beam, gamma knife radiosurgery, etc.) versus RI (radioactive implant, e.g., plaque brachytherapy, etc.) by searching the Surveillance Epidemiology and End Results (SEER) database for men and women aged 20-79 diagnosed with choroidal melanoma (no microscopic confirmation necessary) from 2004-2011, treated with EBRT or RI. Included patients were clinically T1-T4, N0, M0 (AJCC 6th edition, 2004+). Patients who received other types of radiation or more than one radiation modality were excluded. Patients who received surgery as upfront therapy were also excluded. Overall survival (OS) and cause specific survival (CSS) curves were calculated by the Kaplan-Meier method and univariate and multivariate analyses on covariates were calculated by the log-rank test and Cox proportional hazards ratio model. Chi-squared analysis was performed on categorical variables to test their interaction with radiation technique. ResultsA total of 1001 cases (379 EBRT and 622 RI) in the CSS analysis and 1004 cases (380 EBRT and 624 RI) in the OS were analyzed. Most patients had T2 tumors, received RI and were of white race; there was a nearly even split between men and women. In the OS analysis, there were 41 deaths in the EBRT cohort and 65 deaths in the RI cohort. Using the Kaplan-Meier method and the log-rank test, we found no difference between CSS (5 year CSS 88.3% EBRT vs. 88.3% RI p = 0.920) and OS (5 year OS 83.3% EBRT vs. 82.5% RI p = 0.688). Examining each tumor stage subgroup individually (T1-T4) we found no statistically significant difference in OS or CSS in each group, however, there was a trend towards improved OS with EBRT for T1 tumors (5 yr OS 94.9% EBRT vs. 86.6% RI p = 0.08). We analyzed each covariate (radiation type, sex, histology, tumor stage, age at diagnosis, race and year of diagnosis) and found that tumor stage (p=0.001) and age at diagnosis (p = 0.001) were significant on univariate analysis by the log rank test. Using the Cox proportional hazards ratio model, we analyzed these significant covariates and found that both age (p<0.001) HR(Hazard Ratio)=1.044 [1.026-1.062] and tumor stage (p=0.001) T2 HR=1.648 [.989-2.745], T3 HR 2.845 [1.462-5.534], T4 HR 5.739 [2.141-15.382] remained statistically significant on multivariate analysis. A total of 1001 cases (379 EBRT and 622 RI) in the CSS analysis and 1004 cases (380 EBRT and 624 RI) in the OS were analyzed. Most patients had T2 tumors, received RI and were of white race; there was a nearly even split between men and women. In the OS analysis, there were 41 deaths in the EBRT cohort and 65 deaths in the RI cohort. Using the Kaplan-Meier method and the log-rank test, we found no difference between CSS (5 year CSS 88.3% EBRT vs. 88.3% RI p = 0.920) and OS (5 year OS 83.3% EBRT vs. 82.5% RI p = 0.688). Examining each tumor stage subgroup individually (T1-T4) we found no statistically significant difference in OS or CSS in each group, however, there was a trend towards improved OS with EBRT for T1 tumors (5 yr OS 94.9% EBRT vs. 86.6% RI p = 0.08). We analyzed each covariate (radiation type, sex, histology, tumor stage, age at diagnosis, race and year of diagnosis) and found that tumor stage (p=0.001) and age at diagnosis (p = 0.001) were significant on univariate analysis by the log rank test. Using the Cox proportional hazards ratio model, we analyzed these significant covariates and found that both age (p<0.001) HR(Hazard Ratio)=1.044 [1.026-1.062] and tumor stage (p=0.001) T2 HR=1.648 [.989-2.745], T3 HR 2.845 [1.462-5.534], T4 HR 5.739 [2.141-15.382] remained statistically significant on multivariate analysis. Conclusions

Purpose: Stereotactic radiosurgery (SRS) represents a treatment option for patients with brain metastases from small cell lung cancer (SCLC) following prior cranial radiation. Inferior local control has been described. We reviewed our failure patterns following SRS treatment to evaluate this concern.Methods and materials: Individuals with SCLC who received SRS for brain metastases from 2004 to 2011 were identified. Central nervous system (CNS) disease was detected and followed by gadolinium-enhanced, high-resolution magnetic resonance (MR) imaging. SRS dose was prescribed to the tumor periphery. Local recurrence was defined by increasing lesion size or enhancement, MRspectroscopy, and perfusion changes consistent with recurrent disease or pathologic confirmation. Any new enhancing lesion not identified on the SRS planning scan was considered a regional failure. Overall survival (OS) and CNS control were evaluated using the Kaplan-Meier method. Factors predicted to influence outcome were tested by univariate log-rank analysis and Cox regression.Results: Fifteen males and 25 females (median age of 61 years [range, 36-79]) of which 39 received prior brain irradiation were identified. In all, 132 lesions (3.3 per patient) between 0.4 and 4.7 cm received a median dose of 16 Gy (12-22 Gy). Thirteen metastases (10%) ultimately recurred locally with 6-and 12-month control rates of 81% and 69%, respectively. Only 1 of 110 metastases <2 cm recurred. Local failure was more likely for size >2 cm (P < .001) and dose b16 Gy (P < .001). The median OS was 6.5 months, and the time to regional CNS recurrence was 5.2 months. For patients with single brain metastases, both OS (P = .037) and regional CNS recurrence (P = .003) were improved. CNS control (P = .001), and survival (P = .057), were also longer for patients with controlled systemic disease.Conclusions: Local control following SRS for SCLC metastases is achievable for lesions <2 cm. For metastases >2 cm, local failure is more common than expected. Patients with controlled systemic disease and limited CNS involvement would benefit most from aggressive treatment. (C) 2015 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

BACKGROUND:The incidence of bilateral trigeminal neuralgia (TN) is 1-6% of total number of TN cases. Gamma Knife Radiosurgery (GKRS) is effective in treating unilateral TN; however, outcomes of bilateral TN treated by GKRS have not been well evaluated. The purpose of this study is to evaluate the long-term GKRS outcomes of bilateral TN at our institution and compare with our published treatment outcomes of unilateral TN.METHODS:Between 2000 and 2006, eight patients with bilateral TN were treated with GKRS. Data available on seven patients were collected. Facial pain outcomes were defined using the Barrow Neurological Institute pain intensity scale. Outcomes and toxicities were compared to published outcomes of unilateral TN patients treated with GKRS at our institution.RESULTS:The incidence of bilateral TN in our series is 2.3%. Treatment outcomes were excellent in 5/14, good in 1/14, and poor in 8/14. Median follow-up time was 58 months. Median time-to-failure was 38 months. Pain control rate was 80% at 12 months and 65% at 36 months. Bothersome side effects were seen in 4/14 nerves treated. Compared with our long-term unilateral TN cohort, there was no statistically significant difference in outcome, time-to-failure, or rate of toxicity.CONCLUSION:Bilateral TN is rare, and effective treatment is crucial to improve the quality of life of those afflicted. Salvage GKRS is a reasonable treatment modality for individuals with bilateral TN.

PURPOSE: Stereotactic radiosurgery (SRS) following resection of brain metastases is well-tolerated, provides excellent local control and reserves whole-brain radiation therapy for high volume CNS recurrence. We identified criteria to facilitate appropriate candidate selection for SRS based on CNS recurrence and overall survival (OS). METHODS: From 2002-2010, individuals with a KPS >70 who received SRS to the resection cavity for brain metastases were evaluated. The target encompassed the entire cavity defined on MRI, and was treated using Gamma Knife radiosurgery. Follow-up included clinical exam and MRI at 2-3 month intervals. CNS failure was defined by imaging or pathology. Factors predicted to impact OS and CNS control were assessed using log-rank and Cox-regression analyses. RESULTS: 151 consecutive patients with a median follow-up of 5.3 months were identified. Local control was >90% at 1 year and >80% at 2 years. Median OS was 14.2 months with 19% 5-year survival. Patients without systemic disease and those with single metastasis survived significantly longer. Median time to regional CNS failure was 14.5 months. Systemic disease overwhelmingly predicted regional CNS recurrence. Multivariate analysis showed that absence of systemic disease, a single brain metastasis and age were associated with improved OS and regional CNS control. We identified 3 groups: single brain lesion without systemic disease, >2 brain lesions without systemic disease, and those with systemic disease, that predicted OS and CNS control. Median OS was 16.5, 18.3, and 8.1 months, respectively (p < 0.001) and median time to CNS recurrence was 32.8, 15.7 and 8.7 months, respectively (p < 0.001). CONCLUSION: This represents the largest study of SRS following resection of brain metastases. Excellent long-term local control, survival and regional CNS control can be achieved in select patients. Major criteria to identify treatment candidates should include systemic disease status as well as number of brain lesions.

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