, Abstract PURPOSE— To assess the long-term quality of life (QoL) outcomes from a phase III trial comparing conventional (CIMRT) versus hypofractionated (HIMRT) IMRT in patients with localized prostate cancer. METHODS AND MATERIALS— Between 2002 and 2006, 303 men with low- to high-risk prostate cancer were randomized to 76 Gy in 38 fractions (CIMRT) versus 70.2 Gy in 26 fractions (HIMRT). QoL was compared using the Expanded Prostate Cancer Index Composite (EPIC), International Prostate Symptom Score (IPSS), and EuroQoL (EQ5D) questionnaires. The primary outcome of the quality of life analysis was a minimum clinically important difference defined as a 0.5 standard deviation change from baseline for each respective QoL parameter. Treatment effects were evaluated using logistic mixed effects regression models. RESULTS— A total of 286, 299, and 218 patients had baseline EPIC, IPSS, or EQ5D data available and were included in the analysis. Overall, there was no statistically significant difference between the two treatment arms in terms of EPIC, IPSS, or EQ5D scores over time although there was a trend towards lower EPIC urinary incontinence versus patients in the CIMRT arm with long-term follow-up. On multivariable analysis, there was no association between radiation fractionation scheme and any QoL parameter. When examining other clinical factors, lymph node radiation was associated with worse EPIC hormonal scores versus patients receiving no lymph node radiation. In general, QoL outcomes were generally stable over time with the exception of EPIC hormonal and EQ5D scores. CONCLUSIONS— In this randomized prospective study, there were stable QoL changes in patients receiving HIMRT or CIMRT. Our results add to the growing body of literature suggesting that HIMRT may be an acceptable treatment modality in clinically localized prostate cancer. There is no long-term randomized prospective data comparing quality of life outcomes of patients treated with conventional versus hypofractionated radiotherapy. In this randomized phase III trial, patients receiving hypofractionated radiotherapy appeared to have similar long-term quality of life outcomes versus patients receiving conventionally fractionated radiation. These long-term results suggest that hypofractionated radiation can be delivered effectively and safely in a select group of patients with prostate cancer.

INTRODUCTION:To characterize patient reported outcomes for urinary and sexual function using International Prostate Symptom Score (IPSS) and Sexual Health Inventory for Men (SHIM) comparing intensity modulated radiation therapy (IMRT), low dose rate brachytherapy (LDR), post-prostatectomy IMRT (PPRT), and radical prostatectomy (RP).MATERIALS AND METHODS:Patients treated for prostate cancer from 2001-2012 completed self-reported SHIM and IPSS surveys. Subgroups were created by baseline score. Mean change from baseline was determined at each time point for the cohort and subgroups. Statistical analysis was performed with generalized estimating equation method. Incontinence was not captured in the questionnaires.RESULTS:A total of 14,523 IPSS surveys from 3,515 men were evaluated. Patients treated with IMRT experienced a minimal decrease in IPSS score from baseline. PPRT scores did not differ from IMRT at any time point (range: +/- 3 points from baseline in IPSS score over 50 months). LDR had an initial IPSS rise (between 5-10 points on the IPSS over 1-9 months) versus IMRT but returned to comparable levels at 34 months. RP was associated with a lower IPSS versus IMRT. LDR had the largest rise from baseline, with return toward baseline. A total of 2,624 SHIM surveys from 857 men were evaluated. LDR and PPRT did not differ from IMRT at any time point (range: +/- 5 points from baseline in SHIM score for 36 months). RP experienced the largest decline from baseline (up to -7 points on SHIM score), at 3 to 7 months; RP had a larger early decrease in SHIM score versus IMRT between 3 and 22 months, after which there was no difference.CONCLUSIONS:IPSS and SHIM score patterns differed among treatment modalities. These data can be used to predict changes in urinary and sexual function over time based on modality and baseline score.

Purpose: To assess the long-term quality of life (QoL) outcomes from a phase 3 trial comparing 2 modes of intensity modulated radiation therapy (IMRT): conventional IMRT (CIMRT) versus hypofractionated IMRT (HIMRT) in patients with localized prostate cancer.Methods and Materials: Between 2002 and 2006, 303 men with low-risk to high-risk prostate cancer were randomized to 76 Gy in 38 fractions (CIMRT) versus 70.2 Gy in 26 fractions (HIMRT). QoL was compared by use of the Expanded Prostate Cancer Index Composite (EPIC), the International Prostate Symptom Score (IPSS), and EuroQoL (EQ5D) questionnaires. The primary outcome of the QoL analysis was a minimum clinically important difference defined as a 0.5 standard deviation change from baseline for each respective QoL parameter. Treatment effects were evaluated with the use of logistic mixed effects regression models.Results: A total of 286, 299, and 218 patients had baseline EPIC, IPSS, or EQ5D data available and were included in the analysis. Overall, there was no statistically significant difference between the 2 treatment arms in terms of EPIC, IPSS, or EQ5D scores over time, although there was a trend toward lower EPIC urinary incontinence scores in the HIMRT arm. More patients in the HIMRT arm had a lower EPIC urinary incontinence score relative to baseline versus patients in the CIMRT arm with long-term follow-up. On multivariable analysis, there was no association between radiation fractionation scheme and any QoL parameter. When other clinical factors were examined, lymph node radiation was associated with worse EPIC hormonal scores versus patients receiving no lymph node radiation. In general, QoL outcomes were generally stable over time, with the exception of EPIC hormonal and EQ5D scores.Conclusions: In this randomized prospective study, there were stable QoL changes in patients receiving HIMRT or CIMRT. Our results add to the growing body of literature suggesting that HIMRT may be an acceptable treatment modality in clinically localized prostate cancer. (C) 2016 Elsevier Inc. All rights reserved.

To report the 8-year results of hypofractionated radiation therapy (HRT) with an incorporated boost and to compare toxicities and outcomes to propensity matched conventional fractionation (CRT) with sequential boost for early-stage breast cancer. The HRT cohort included 75 patients (pts) treated on a prospective Phase II study and 172 pts treated off trial in a similar manner. Inclusions were breast conservation, pts >18 years, Tis-T2, stage 0–II, and whole-breast IMRT with incorporated boost. The whole-breast received 2.25 Gy per fraction (fx) to 45 Gy with an incorporated tumor bed boost to 2.8 Gy per fx for a total of 56 Gy in 20 fx over 4 weeks. Women treated with CRT (whole-breast IMRT to 50 Gy in 2 Gy fx plus a sequential 10–16 Gy boost) were matched to HRT pts in a 2:1 ratio without replacement using a propensity score algorithm for age, T stage, systemic therapy use, bra cup size, type of boost (photon vs electron), grade, lymphovascular invasion, and ER/PR status. Adverse events during RT were considered acute, while events >1.5months after RT were considered late. All side effects were graded based on CTCAE v3. Patient reported cosmesis was scored using the Harvard scale (1 = excellent, 2 = good, 3 = fair, 4 = poor). Kaplan-Meier curves and Cox proportional hazard models with robust standard errors were used to estimate local control (LC). Proportions were evaluated using Mantel-Haenszel tests to account for the effect of matching. Median follow-up was 52 months (range, 3.5–130). Median age was 56 years (range, 31–88). The HRT patients included 19% Tis, 65% T1, and 16% T2 tumors; 86% were node negative. Eighty percent had negative margins, 18% had close (>0 and <2 mm) margins, and 2% had positive margins. The majority of pts received systemic therapy (45% endocrine therapy, 10% chemotherapy, and 22% both). We matched 241 of the 247 HRT pts to 482 CRT pts with no significant differences between groups except more unknown grade in CRT group. Eight-year LC was 97.5% for HRT versus 96.6% in the CRT group (P = .78). There was no significant difference in any grade acute skin erythema in HRT versus CRT (91.3% vs 90.9%, P = .89). Grade 2+ acute side effects were more frequent in CRT versus HRT (47.1% vs 18.7%, P < 0.01). There was no difference in any grade late side effects experienced in the CRT versus HRT group (47.7% vs 41.5%, P = .12); 79% of late side effects in both groups were grade 1. The most common late side effects were edema, hyperpigmentation, erythema, and fibrosis. Mean pt reported cosmesis scores were similar at 3 years for HRT versus CRT (1.9 vs 1.9). The 4-week course of hypofractionated whole-breast radiation with incorporated boost was associated with excellent long-term LC, less acute side effects, similar cosmesis, and late side effects compared to conventional fractionation with sequential boost.

A small decrease in testosterone level has been documented after prostate irradiation, possibly owing to the incidental dose to the testes. Testicular doses from prostate external beam radiation plans with either intensity-modulated radiation therapy (IMRT) or volumetric-modulated arc therapy (VMAT) were calculated to investigate any difference. Testicles were contoured for 16 patients being treated for localized prostate cancer. For each patient, 2 plans were created: 1 with IMRT and 1 with VMAT. No specific attempt was made to reduce testicular dose. Minimum, maximum, and mean doses to the testicles were recorded for each plan. Of the 16 patients, 4 received a total dose of 7800 cGy to the prostate alone, 7 received 8000 cGy to the prostate alone, and 5 received 8000 cGy to the prostate and pelvic lymph nodes. The mean (range) of testicular dose with an IMRT plan was 54.7 cGy (21.1 to 91.9) and 59.0 cGy (25.1 to 93.4) with a VMAT plan. In 12 cases, the mean VMAT dose was higher than the mean IMRT dose, with a mean difference of 4.3 cGy (p = 0.019). There was a small but statistically significant increase in mean testicular dose delivered by VMAT compared with IMRT. Despite this, it unlikely that there is a clinically meaningful difference in testicular doses from either modality.

Data are limited regarding the efficacy of adjuvant radiation therapy (RT) alone for elderly women with low-risk breast cancer. The present study of > 500 women identified a group of women for whom adjuvant RT, without endocrine therapy (ET), could result in acceptable outcomes. The study also explored the influence of ET nonadherence and tumor size on outcomes.Background: Randomized data examining adjuvant radiation therapy (RT) alone in elderly women with low-risk, hormone receptor-positive (HR+) breast cancer is lacking. We investigated the outcomes for elderly women treated with adjuvant RI alone versus RT plus endocrine therapy (ET) after breast-conserving surgery. Patients and Methods: We queried our institutional breast cancer database for the following patients: age > 65 years, stage T1-T2NO, HR+, and treatment with breast-conserving surgery, including adjuvant RT. The chi(2) analysis identified significant baseline differences between the groups. Cox proportional hazard methods identified predictors of endpoints on multivariate analysis. Kaplan-Meier estimates of survival were compared using the log-rank test. Results: A total of 504 patients were identified, 311 had undergone RT plus ET (62%) and 193, RT alone (38%). The median follow-up time was 88 months. The RI-alone group versus RT plus ET group had different median age (72 vs.71 years, P < .001), different median tumor size (1 vs. 1.3 cm, P < .001), lower grade (40% vs. 29%, P = .05), and fewer close or positive margins (11% vs. 19%, P = .01). The adherence rate to prescribed ET was 70%. Tumor size predicted an increased risk of distant metastasis (DM) (hazard ratio, 1.96; 95% confidence interval [Cl], 1.23-3.13) and worse disease-free survival (DFS) (hazard ratio, 1.86; 95% Cl, 1.22-2.86). ET nonadherence versus adherence predicted for risk of DM (hazard ratio, 5.03; 95% Cl, 1.98-12.66) and DFS (HR, 4.24; 95% Cl, 1.9-10.3). Of the women with DM, 83.8% had tumors > 1 cm in size. Conclusion: ET nonadherence and tumor size > 1 cm predicted an increased risk of DM and worse DFS, favoring the addition of ET in this group. However, RT alone for women with tumors less than or equal to 1 cm may be appropriate. (C) 2015 Elsevier Inc. All rights reserved.

PURPOSE:Characterize use of postprostatectomy radiation (PPRT) for patients with prostate cancer at an NCI-designated comprehensive cancer center.METHODS:We queried our prospective prostate cancer database for patients treated with 60 to 68 Gy of radiation therapy (RT) to the prostate bed after prostatectomy from 2003 to 2011. Prostatectomy cases were obtained from billing records. Patients with an intact prostate treated with definitive RT served as a control for the change in volume of patients with prostate cancer treated in the department. Chi-square analysis assessed differences between adjuvant and salvage RT cohorts. Spearman correlation assessed yearly trends in prostate-specific antigen (PSA) level at the time of referral for RT. Linear regression models tested trends for number of PPRT cases, prostatectomies, and patients with intact prostate receiving radiation across years.RESULTS:PPRT was used to treat 475 men at Fox Chase Cancer Center from 2003 to 2011 (83 adjuvant and 392 salvage). Over time, an increased proportion of patients receiving RT to the prostate were treated with PPRT. No increase was seen in the proportion of patients treated with adjuvant RT compared with salvage RT (P=.5). Patients receiving adjuvant RT were younger, had higher pathologic Gleason score, pathologic T stage, and rates of positive margins than those receiving salvage RT. Pre-RT PSA values were inversely correlated with year (P=.005). The number of patients referred for salvage RT with a PSA of 0.5 ng/mL or less increased significantly from 7.9% in 2003 to 26.6% in 2011 (P=.002).CONCLUSIONS:A larger proportion of patients treated with RT for localized prostate cancer are now receiving PPRT. No increase was seen in the proportion of patients treated with adjuvant RT. Over time, patients with lower PSAs were referred for salvage RT.

Curvature of the scalp and proximity to the brain makes the treatment of scalp tumors challenging. Practitioners often accept sub-optimal plans with modulated photons or matched electron fields in an attempt to cover the target and avoid unnecessary brain irradiation. The aim of this study is to evaluate the ability of modulated electron radiation therapy (MERT) to decrease radiation dose to the brain for large scalp targets. CT planning scans from 5 patients with skin cancers of the scalp measuring > 10 cm previously treated with volumetric modulated arc therapy (VMAT) to 5000 cGy in 20 fractions were unarchived in accordance with an institutional review board approved protocol. All cases were replanned with MERT. MERT cases were prescribed to the 90% isodose line and VMAT cases were normalized so 95% of the PTV received 5000 cGy. Using an in-house Monte Carlo (MC) based inverse treatment planning system, MERT treatment plans were calculated with the goal of covering the target and minimizing dose to the brain. Minimum planning target volume dose (PTVmin), dose to 95% (D95) of planning target volume (PTV), mean dose to the brain, and the percentage volume of the brain receiving 20 Gy (V20) were calculated. VMAT and MERT results were compared using Wilcoxon signed-rank tests. Plans were designed for delivery using a motorized electron multi-leaf collimator (eMLC) that attaches to the head of the linear accelerator. The eMLC has 27 pairs of tungsten leaves with a 0.56 cm width and 2 cm thickness. Treatment time for the MERT plans was estimated by multiplying the slowest leaf speed by the distance needed to travel from parking position to the center and then multiplying by the number of segments in the plan. The maximum dimension of the PTV ranged from 11-23 cm. The estimated treatment delivery time for the MERT plans ranged from 4-15 minutes. PTV coverage between VMAT vs MERT plans: mean PTVmin (3486 cGy vs 3393 cGy, p = 0.99) and mean D95 (5000 cGy vs 4804 cGy, p = 0.06) (see Table). Mean brain dose trended lower for MERT plans (1032 cGy vs 406 cGy, p = 0.06), as did V20 (16.9% vs 6.8%, p = 0.06). We successfully developed MERT treatment plans for 5 patients with large scalp lesions that were able to cover the PTV and show a trend for decreased dose to the brain when compared to the VMAT plans, while maintaining estimated treatment time ≤ 15 min. MERT technology may allow for improvement in conformity for shallow tumors, especially in the head and neck region, where sparing deeper radiosensitive tissues is critical.Digital Poster Abstract 1083; TablePatientVMAT PTVmin (cGy)MERT PTVmin (cGy)VMAT PTV D95 (cGy)MERT PTV D95 (cGy)VMAT Brain Mean Dose (cGy)MERT Brain Mean Dose (cGy)VMAT Brain V20 (%)MERT Brain V20 (%)144343145500047508003309.15.422606403050004830234997764.521.9323913799500048506102644.94.45443764220500048409041607.00.8536211770500047504982992.01.6Mean348633935004804103240616.96.8 Open table in a new tab

Purpose/Objective(s)Trends in PROs for treatment modalities in localized PCa are poorly understood. We aim to report trends in PROs for urinary and sexual function using American Urologic Association Symptom Score (AUA) and Sexual Health Inventory for Men (SHIM) comparing intensity modulated radiation therapy (IMRT), low dose rate brachytherapy (LDR), post-prostatectomy IMRT (PPRT), and radical prostatectomy (RP).Materials/MethodsWe used our prospectively-collected institutional database to create cohorts of patients (pts) treated for PCa 2001-2012 who completed self-reported SHIM and AUA surveys. AUA and SHIM were evaluated separately. AUA scores obstructive urinary symptoms but not incontinence; lower is better. SHIM scores erectile/sexual function; higher is better. For inclusion, patients (pts) needed a baseline (BL) pre-treatment score (< 6 months from LDR/RP or start of IMRT/PPRT) and ≥ 1 follow-up score. Scores were grouped into intervals corresponding to follow-up schedule. If a pt had ≥ 1 score in an interval, those scores were averaged. Subgroups were created by BL score. Mean change from BL was determined at each time point for the cohort and subgroups. Analysis used generalized estimating equation (GEE) method which accounts for within-pt correlation over time to compare change from BL to IMRT (control).ResultsThe AUA cohort examined 14,523 surveys from 3,515 men. Median follow-up was 28 months. BL score (p < 0.01) and median age (IMRT: 69, LDR: 64, PPRT: 62, RP: 59, p < 0.01) differed among groups. Pts treated with IMRT experienced a minimal decrease in AUA score from BL. PPRT did not differ from IMRT at any time point. LDR had an initial AUA rise vs IMRT but returned to comparable levels at 34 months. RP was associated with a lower AUA vs IMRT at all time points. LDR had largest rise from BL, + 10.6 points at < 3 months with slow return toward baseline. Scores are demonstrated in the Table. The SHIM cohort examined 2,624 surveys from 857 men. Median follow-up was 18 months. BL score (p < 0.01) and median age (IMRT: 68, LDR: 63, PPRT: 63, RP: 68, p < 0.01) differed among groups. LDR and PPRT did not differ from IMRT at any time point. RP experienced the largest decline from BL, -7.4 points at 3-7 months; RP had a larger early decrease in SHIM score vs IMRT up to 22 months, after which there is no difference.ConclusionsOral Scientific Abstract 180; TableAUAMean BaselineAve Change < 3 moAve Change 3-7 moAve Change 7-13 moAve Change 13-19 moAve Change 19-25 moAve Change 25-31 moAve Change 31-37 moAve Change 37-49 moIMRT (n = 2371)8.0-0.5-0.7-0.8-0.9-1.2-1.0-0.8-0.6LDR (n = 308)5.810.6*7.2*4.7*3.4*2.5*2.1*0.81.3PPRT (n = 411)5.81.30.4*0.41.01.31.30.60.7RP (n = 425)7.30.9*-0.8*-2.5*-1.7*-1.7*-1.6*-2.2*-1.9*SHIMIMRT (n = 376)16.1-3.4-2.1-3.2-3.6-3.1-3.5-3.2LDR (n = 80)19.1-3.0-4.5-3.7-4.7-3.4-5.4-5.3PPRT (n = 145)12.10.0-0.9-0.1-0.40.90.2-0.5RP (n = 256)20.2-3.9-7.4*-6.9*-7.3*-6.1-5.7-3.7*Significantly different than IMRT (P < .05), comparison based on model results (not shown) Open table in a new tab Purpose/Objective(s)Trends in PROs for treatment modalities in localized PCa are poorly understood. We aim to report trends in PROs for urinary and sexual function using American Urologic Association Symptom Score (AUA) and Sexual Health Inventory for Men (SHIM) comparing intensity modulated radiation therapy (IMRT), low dose rate brachytherapy (LDR), post-prostatectomy IMRT (PPRT), and radical prostatectomy (RP). Trends in PROs for treatment modalities in localized PCa are poorly understood. We aim to report trends in PROs for urinary and sexual function using American Urologic Association Symptom Score (AUA) and Sexual Health Inventory for Men (SHIM) comparing intensity modulated radiation therapy (IMRT), low dose rate brachytherapy (LDR), post-prostatectomy IMRT (PPRT), and radical prostatectomy (RP). Materials/MethodsWe used our prospectively-collected institutional database to create cohorts of patients (pts) treated for PCa 2001-2012 who completed self-reported SHIM and AUA surveys. AUA and SHIM were evaluated separately. AUA scores obstructive urinary symptoms but not incontinence; lower is better. SHIM scores erectile/sexual function; higher is better. For inclusion, patients (pts) needed a baseline (BL) pre-treatment score (< 6 months from LDR/RP or start of IMRT/PPRT) and ≥ 1 follow-up score. Scores were grouped into intervals corresponding to follow-up schedule. If a pt had ≥ 1 score in an interval, those scores were averaged. Subgroups were created by BL score. Mean change from BL was determined at each time point for the cohort and subgroups. Analysis used generalized estimating equation (GEE) method which accounts for within-pt correlation over time to compare change from BL to IMRT (control). We used our prospectively-collected institutional database to create cohorts of patients (pts) treated for PCa 2001-2012 who completed self-reported SHIM and AUA surveys. AUA and SHIM were evaluated separately. AUA scores obstructive urinary symptoms but not incontinence; lower is better. SHIM scores erectile/sexual function; higher is better. For inclusion, patients (pts) needed a baseline (BL) pre-treatment score (< 6 months from LDR/RP or start of IMRT/PPRT) and ≥ 1 follow-up score. Scores were grouped into intervals corresponding to follow-up schedule. If a pt had ≥ 1 score in an interval, those scores were averaged. Subgroups were created by BL score. Mean change from BL was determined at each time point for the cohort and subgroups. Analysis used generalized estimating equation (GEE) method which accounts for within-pt correlation over time to compare change from BL to IMRT (control). ResultsThe AUA cohort examined 14,523 surveys from 3,515 men. Median follow-up was 28 months. BL score (p < 0.01) and median age (IMRT: 69, LDR: 64, PPRT: 62, RP: 59, p < 0.01) differed among groups. Pts treated with IMRT experienced a minimal decrease in AUA score from BL. PPRT did not differ from IMRT at any time point. LDR had an initial AUA rise vs IMRT but returned to comparable levels at 34 months. RP was associated with a lower AUA vs IMRT at all time points. LDR had largest rise from BL, + 10.6 points at < 3 months with slow return toward baseline. Scores are demonstrated in the Table. The SHIM cohort examined 2,624 surveys from 857 men. Median follow-up was 18 months. BL score (p < 0.01) and median age (IMRT: 68, LDR: 63, PPRT: 63, RP: 68, p < 0.01) differed among groups. LDR and PPRT did not differ from IMRT at any time point. RP experienced the largest decline from BL, -7.4 points at 3-7 months; RP had a larger early decrease in SHIM score vs IMRT up to 22 months, after which there is no difference. The AUA cohort examined 14,523 surveys from 3,515 men. Median follow-up was 28 months. BL score (p < 0.01) and median age (IMRT: 69, LDR: 64, PPRT: 62, RP: 59, p < 0.01) differed among groups. Pts treated with IMRT experienced a minimal decrease in AUA score from BL. PPRT did not differ from IMRT at any time point. LDR had an initial AUA rise vs IMRT but returned to comparable levels at 34 months. RP was associated with a lower AUA vs IMRT at all time points. LDR had largest rise from BL, + 10.6 points at < 3 months with slow return toward baseline. Scores are demonstrated in the Table. The SHIM cohort examined 2,624 surveys from 857 men. Median follow-up was 18 months. BL score (p < 0.01) and median age (IMRT: 68, LDR: 63, PPRT: 63, RP: 68, p < 0.01) differed among groups. LDR and PPRT did not differ from IMRT at any time point. RP experienced the largest decline from BL, -7.4 points at 3-7 months; RP had a larger early decrease in SHIM score vs IMRT up to 22 months, after which there is no difference. ConclusionsOral Scientific Abstract 180; TableAUAMean BaselineAve Change < 3 moAve Change 3-7 moAve Change 7-13 moAve Change 13-19 moAve Change 19-25 moAve Change 25-31 moAve Change 31-37 moAve Change 37-49 moIMRT (n = 2371)8.0-0.5-0.7-0.8-0.9-1.2-1.0-0.8-0.6LDR (n = 308)5.810.6*7.2*4.7*3.4*2.5*2.1*0.81.3PPRT (n = 411)5.81.30.4*0.41.01.31.30.60.7RP (n = 425)7.30.9*-0.8*-2.5*-1.7*-1.7*-1.6*-2.2*-1.9*SHIMIMRT (n = 376)16.1-3.4-2.1-3.2-3.6-3.1-3.5-3.2LDR (n = 80)19.1-3.0-4.5-3.7-4.7-3.4-5.4-5.3PPRT (n = 145)12.10.0-0.9-0.1-0.40.90.2-0.5RP (n = 256)20.2-3.9-7.4*-6.9*-7.3*-6.1-5.7-3.7*Significantly different than IMRT (P < .05), comparison based on model results (not shown) Open table in a new tab *Significantly different than IMRT (P < .05), comparison based on model results (not shown)

There is limited data on the dose received by the lacrimal gland (LG) during whole brain radiation therapy (WBRT) and the associated clinical symptoms. Radiation dose tolerance of the LG has been described between 24-40 Gy in 2 Gy fractions (fx). We aim to determine the radiation dose given to the LG during WBRT using palliative fractionation schemes and the acute clinical symptoms associated with the radiation dose. Between July 2012 and April 2013, 58 patients (pts) with brain metastases and no history of radiation to the ocular structures received WBRT. Of these, 40 pts met the inclusion criteria of having received at least 25 Gy WBRT dose and had follow-up of at least 21 days. 80 LGs were contoured and dose distribution was calculated in the Eclipse treatment planning system. The LG was contoured according to an atlas developed in conjunction with a neuroradiologist for this project. Acute eye symptoms were gathered from chart review and categorized by Common Terminology Criteria for Adverse Events v.4.0. The short median survival of this patient population prohibits definitive examination of late effects. Equivalent dose in 2 Gy fractions (EQD2) was calculated assuming α/B of 10. Logistic regression was performed to evaluate dose-response relationship and an exploratory recursive partitioning analysis was used to identify a dose threshold. Median follow-up time was 3.6 months, median overall survival was 4.5 months. WBRT prescriptions were 30 Gy in 10 fx (n = 32), 37.5 Gy in 15 fx (n = 4), 25 Gy in 10 fx (n = 2), 37.5 Gy in 20 fx (n = 1), and 35 Gy in 14 fx (n = 1). The median LG volume was 0.71 cc. The median LG mean dose was 29.2 Gy, corresponding to an EQD2 of 31.4 Gy. The LG median minimum dose to 0.1 cc was 14.9 Gy. The median maximum dose to 0.1 cc was 32.2 Gy, corresponding to an EQD2 of 35.5 Gy. Of the 40 pts, 5 pts (12.5%) experienced acute grade 1 toxicity, and one patient (2.5%) experienced grade 2 conjunctivitis one month after WBRT. Grade 1 toxicities were conjunctivitis, blurred vision, and watering eye. There were no > grade 3 toxicities. A dose-response relationship was noted: the odds ratio for eye toxicity was 1.32 (95% CI 1.02-1.70) per 1 Gy difference in LG mean dose. LG mean dose of 30.6 Gy was identified as the optimal threshold dose in this small dataset. For pts with mean LG dose 30.6 Gy, acute grade 1-2 toxicity was seen in 3.9% vs 35.7% of pts (p = 0.02). WBRT delivers radiation to the LG at or exceeding commonly reported radiation tolerance as calculated by EQD2. WBRT was associated with a 15% rate of acute grade 1-2 eye symptoms in this series, and symptom incidence was associated with LG mean dose. These data suggest that when treating with WBRT, contouring the LG and limiting mean radiation dose to the LG to <30.6 Gy in 3 Gy/fx can decrease the incidence of acute eye symptoms to <5%.

41 Background: The radiation target for intensity modulated radiation therapy (IMRT) in high-risk prostate cancer (HRPC) includes both the prostate and seminal vesicles (SV). Inclusion of the regional lymph nodes (LN) has considerable variation in daily practice. Currently used prescriptions are 80 Gy to prostate and proximal SV, with 56Gy to the distal SV with (P/SV+LN) or without the pelvic LN (P/SV). The same P/SV prescription is used for intermediate risk prostate cancer (IRPC). We report the association between inclusion of the LN and toxicity for men treated from 2001 to 2009. Methods: 1,160 men treated for HRPC and IRPC with IMRT were identified in our clinical database. All patients had simulation with both CT and MRI, and utilized daily image guidance. Toxicity data were obtained from chart review. Statistical analysis was performed utilizing log rank test. Results: 408 patients were in the P/SV+LN group. There was no difference between the groups in regard to age, race, RT duration, or smoking. Median prescription dose was 78 Gy in both groups. Median follow-up was 44 months. A higher rate of late GI toxicity was seen in the group of patients treated to P/SV+LN (p<0.01), see Table. No difference was seen in toxicity >grade 2 for acute GU (33.1% vs. 30.2%, p=0.31), acute GI (5.9% vs. 3.5%, p=0.05), or late GU toxicity (13.7% vs. 13.0%, p=0.74) for P/SV+LN vs. P/SV alone at 5 years. MVA was performed for late GI toxicity controlling for radiation dose, length of radiation course, and use of androgen deprivation. Inclusion of LN RT remained a significant predictor of late GI toxicity (HR=2.0, p=0.02). For those with late GI toxicity, the most common symptoms were bleeding (69.5%), increased frequency of bowel movements (26.6%), fecal incontinence (15.7%), and proctitis (14.9%). Conclusions: Delivery of 56 Gy to the pelvic LN results in a significant increase in grade 2 or higher late GI toxicity with a HR of 2.0 in the setting of treatment with IMRT. A decision to treat the pelvic LN in HRPC should be weighed against the increase in late GI toxicity. [Table: see text]

BACKGROUND There is conflicting evidence regarding the benefit of postmastectomy radiation therapy (PMRT) for pathologic stage T3N0M0 breast cancers. We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database to investigate the benefit of PMRT in this patient population. METHODS We queried the SEER database for T3N0M0 breast cancer patients diagnosed from 2000 to 2010 who underwent modified radical mastectomy. We excluded males, patients with unknown radiation timing/type, other primary tumors, and survival <6 months. A total of 2525 patients were included in the analysis. We performed univariate and multivariate statistical analysis using chi-square tests, log-rank tests, and Cox proportional hazards regression. The primary endpoints were overall survival (OS) and cancer-specific survival (CSS). RESULTS Of the 2525 patients identified, 1063 received PMRT. The median follow-up was 56 months (range, 6-131 months). On univariate analysis, PMRT improved OS (76.5% vs 61.8%, P<.01) and CSS (85.0% vs 82.4%, P<.01) at 8 years. The use of PMRT remained significant on multivariate analysis: PMRT improved OS (hazard ratio 0.63, P<.001) and CSS (hazard ratio 0.77, P=.045). Low tumor grade (P<.01) and marital status of married (P=.01) also was a predictor of improved CSS on multivariate analysis. CONCLUSIONS PMRT was associated with significant improvements in both CSS and OS in patients with T3N0M0 breast cancers treated with modified radical mastectomy from 2000 to 2010. PMRT should be strongly considered in T3N0M0 patients.Postmastectomy radiation therapy is associated with significant improvements in overall and cause-specific survival in patients with T3N0M0 breast cancers treated with modified radical mastectomy from 2000 to 2010 in the SEER database. Postmastectomy radiation therapy should be strongly considered for patients who have T3N0M0 tumors. (c) 2014 American Cancer Society.

Purpose: Radioembolization is an emerging therapeutic option for the treatment of metastatic and primary tumors of the liver. Simple formulas are currently utilized in order to prescribe the appropriate activity. While the activity infused to each patient is known, limited data is available concerning the delivered dose. This makes correlation of response to dose impossible. The aim of this study is to establish a method for calculation of dose delivered to intrahepatic targets. Methods: Six patients were enrolled in this study as part of one approved clinical trial. All patients underwent radioembolization for primary or metastatic liver tumor(s). Each patient underwent a post‐treatment PET‐CT for the quantification of activity of Yttrium‐90 labeled microspheres. The absorbed dose is calculated as the convolution of the pre‐calculated dose kernel with the PET‐measured activity. Results: Four patients underwent treatment with SIR‐Spheres for liver metastases from colorectal cancer and 2 patients were treated with Therasphere for hepatocellular cancer. A total of 11 target tumors were contoured on post‐treatment PET‐CT scans for dosimetric evaluation. Mean prescription activity was 1.51 GBq (range: 0.58 to 3.29 GBq). The resulting mean maximum measured dose to targets was 167 Gy (range: 71 to 311 Gy). Mean minimum dose to 70% of target (D70) was 54 Gy (range: 29 to 83 Gy). Mean minimum dose to 90% of target (D90) was 36 Gy (range: 13 to 58 Gy). The mean maximum dose for Therasphere and SIR‐spheres was 266 Gy versus 111 Gy. Conclusion: This pilot project demonstrates that dose can be calculated in patients after radioembolization, utilizing PET‐CT measured activity. Although this represents preliminary work with a small number of patients, the doses to patients treated with Therasphere may be larger. This process could lay the foundation for more sophisticated dose prescription methods in the future.

The radiation target defined for IMRT for intermediate risk prostate cancer (IRPC) includes both the prostate and seminal vesicles (SV). The amount of SV included has considerable variation. Common prescriptions are 80Gy to prostate and proximal seminal vesicles (PSV), with or without 56Gy to the distal seminal vesicles (DSV). PSV is defined as the most caudal 1cm of SV. We report the association between inclusion or exclusion of the SV and their relationship to toxicity and clinical outcomes for men treated at Fox Chase Cancer Center (FCCC) with IMRT from 2001 to 2008.

Whole stomach radiation therapy is often used in the management of gastric lymphoma. However, very limited data exist with regard to planning target volume requirements for the whole stomach. This study retrospectively analyzed daily megavoltage computed tomographic (CT) scans of gastric lymphoma patients in order to help determine the interfraction variation of the stomach position.Forty-one daily megavoltage CT images from 3 gastric lymphoma patients were used for stomach contouring. Each patient's megavoltage CT images were rigidly registered to their CT simulation data sets, and the margin in each direction that covered at least 95% of the daily stomach volumes was computed using a simple grid search. Patient setup variation was also calculated from the daily patient shifts. The organ motion margin was then added to the setup margin to render the total margin.A uniform margin of 2.2 cm is required to cover 95% of the stomach over the treatment course. However, direction-specific margins were observed from 1.72, 1.88, 0.92, 2.23, 1.90, and 0.86 cm for the right, left, posterior, anterior, superior, and inferior directions, respectively.The results of this study provide helpful 3-dimensional volumetric information to the limited existing data on margin requirements for whole stomach radiation therapy.

Androgen deprivation therapy is commonly used in combination with radiotherapy as part of the definitive treatment for men with clinically localized and locally advanced prostate cancer. Androgen deprivation has been associated with a wide range of iatrogenic effects impacting a variety of body systems including metabolic, musculoskeletal, cardiovascular, neurocognitive, and sexual. This review aims to provide the radiation oncology community with the knowledge to monitor and manage androgen deprivation therapy toxicity in an effort to provide the highest level of care for patients and to minimize the iatrogenic effects of androgen deprivation as much as possible.

Background: Absolute lymphocyte count (ALC) is a laboratory value commonly obtained during workup of patients with Merkel cell carcinoma (MCC).Objective: We report the prognostic impact of ALC as a surrogate of immune status in MCC.Methods: A complete blood cell count was available for 64 patients with MCC in the month before definitive surgery, chemotherapy, or radiation. Statistical analysis was performed with classification and regression tree analysis, log rank test, and Cox model.Results: Median overall survival (OS) for the cohort was 97 months. Median OS for patients with an ALC less than 1.1 k/mm(3) was 18.8 versus 110.1 months for those with ALC greater than or equal to 1.1 k/mm(3) (P = .002, hazard ratio 0.29). Multivariate analysis of OS controlling for ALC, sex, stage, adjuvant chemotherapy, hematologic malignancy, and immunosuppression demonstrated ALC as a prognostic factor (P = .03). Disease-free survival at 36 months for ALC less than 1.1 k/mm(3) was 26.9% versus 64.4% for those with ALC greater than or equal to 1.1 k/mm(3) (P = .01). ALC was not a significant predictor for disease-free survival on multivariate analysis (P = .12).Limitations: This is a single-institution retrospective data set.Conclusion: ALC is associated with OS but not disease-free survival in MCC using a threshold of less than 1.1 k/mm(3). This test may provide additional prognostic information for patients with MCC.