Melissa A. Frick

Outcomes of invasive mediastinal nodal staging versus positron emission tomography staging alone for early-stage non-small cell lung cancer treated with stereotactic body radiation therapy

BACKGROUND The benefit of invasive mediastinal nodal staging (IMNS) in addition to positron emission tomography-computed tomography (PET/CT) is undefined for early stage non-small cell lung cancer (NSCLC). This multi-institutional investigation aimed to evaluate outcomes and patterns of failure in patients staged with PET/CT with or without additional IMNS. METHODS Two academic centers assessed all consecutive patients staged with PET/CT for early-stage, primary lung NSCLC (cT1-2aN0M0) treated with SBRT. Local recurrence-free survival (LRFS), nodal recurrence-free survival (NRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were calculated using Kaplan-Meier methodology. Univariate and multivariate Cox proportional hazards modeling addressed factors associated with outcomes. RESULTS Overall, 180 patients (199 lesions) were staged with PET/CT alone and 56 patients (58 lesions) underwent additional IMNS. Among patients receiving IMNS, 52 (93%) underwent EBUS and 4 (7%) underwent mediastinoscopy. At a median follow-up of 33.5 months (range, 1.9-80.9 months), there was no significant difference in LRFS (37 vs. 47 months, p=0.309), NRFS (34 vs. 42 months p=0.370), DMFS (36 vs. 47 months, p=0.234) or OS (37 vs. 47 months, p=0.236) between patients undergoing PET/CT-only versus PET/CT+IMNS staging, respectively. Receipt of IMNS did not correlate with any outcome on either univariate or multivariate analysis (p>0.05). Patterns of failure in both groups were similar, including crude isolated nodal failure rates (8% PET/CT-only versus 14% PET+IMNS group, p=0.202). CONCLUSIONS Patients undergoing IMNS had similar survival and patterns of recurrence as those receiving PET/CT alone. Further study, ideally prospectively, is needed to determine which subgroups might benefit from IMNS.

Survivorship after lower gastrointestinal cancer: Patient-reported outcomes and planning for care

There is significant need for quality follow‐up care to optimize long‐term outcomes for the growing population of lower gastrointestinal (GI) cancer survivors. Patient‐reported outcomes (PROs) provide valuable information regarding late and long‐term effects (LLTEs).

Survivorship and the chronic cancer patient: Patterns in treatment-related effects, follow-up care, and use of survivorship care plans

The survivorship needs of patients living with chronic cancer (CC) and their use of survivorship care plans (SCPs) have been overlooked and underappreciated.

A prospective study of proton reirradiation for recurrent and secondary soft tissue sarcoma

BACKGROUND AND PURPOSE Proton reirradiation for sarcoma has not been previously described. We hypothesized that this strategy would provide favorable toxicity and survival outcomes. MATERIAL AND METHODS Patients with soft tissue sarcoma in a previously-irradiated field were enrolled on a prospective trial of proton reirradiation. The primary endpoint was provider-reported acute toxicity. Secondary endpoints included late toxicities, local control, and overall survival. RESULTS 23 patients underwent proton reirradiation. Median time between radiation courses was 40.7months (range 10-272). No grade 4-5 toxicities were observed. One patient (4%) experienced acute grade 3 dysphagia. Common grade 2 acute toxicities were fatigue (26%), anorexia (17%), and urinary incontinence (13%). There were two grade 3 late wound infections (10%) and one grade 3 late wound complication (5%). Grade 2 late complications included lymphedema (10%), fracture (5%), and fibrosis (5%). At a median follow-up of 36months, the 3-year cumulative incidence of local failure was 41% (95% CI [20-63%]). Median overall survival and progression-free survival were 44 and 29months, respectively. In extremity patients, amputation was spared in 7/10 (70%). CONCLUSIONS Proton reirradiation of recurrent/secondary soft tissue sarcomas is well tolerated. While longer follow-up is needed, early survival outcomes in this high-risk population are encouraging.

Survivorship after treatment of pancreatic cancer: insights via an Internet-based survivorship care plan tool

Pancreatic cancer survivors face a unique set of challenges in survivorship, yet structured survivorship care planning is lacking in practice. Survivorship care plans (SCPs) are an essential part of quality cancer care and can facilitate the transition following active treatment; the use of SCPs in pancreatic cancer survivors, however, has not been explored. With a convenience sample of 117 pancreatic cancer survivors and proxies who used an Internet-based SCP tool, we examined treatment details, patient-reported outcomes, and survivorship practices. Thirty-one percent of survivors were 2 years or greater from diagnosis with a median current age of 62 years. Most patients had received multimodality therapy (67%): 68%, 86%, and 43% reported surgical intervention, intravenous chemotherapy, and radiation therapy for their pancreatic cancer, respectively. Survivors commonly reported fatigue, cognitive change, neuropathy, pancreatic insufficiency, and chronic radiation dermatitis related to treatment. Most survivors are managed (47%) or co-managed (35%) by an oncology specialist; however, this percentage decreases over time with consequent increase in management by primary care providers alone. Only 5% had previously been offered an SCP. Of the 24 users who responded to a follow-up satisfaction survey, 83% indicated they would share the SCP with their healthcare team although half of respondents felt it should include more information. In all, our results demonstrate that there is a population of pancreatic cancer survivors who exist and seek survivorship support although structured survivorship care planning is lacking in practice. SCPs have a potentially valuable role for these survivors via communication of treatment-related effects and coordination across multidisciplinary healthcare teams. Further development and evaluation of SCPs is needed for this underserved survivor population.

Patient-reported survivorship care practices and late effects after treatment of Hodgkin (HL) and non-Hodgkin lymphoma (NHL).

PURPOSE Multimodal treatment of Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) yields excellent outcomes; however, survivors are at risk of developing myriad late and long-term effects. METHODS From a convenience sample of 964 survivors of HL (37%) and NHL (63%) using a publicly available Internet-based survivorship care plan (SCP) tool between 2011 and 2016, we examined patient-reported cancer care, toxicities, and survivorship care data. RESULTS Of all survivors, 67% were female and 84% were white and 88% were free of cancer. Median age of diagnosis was 28 years for survivors of HL and 49 years for NHL. Many survivors reported treatment with chemotherapy (92%), surgery (52%), and/or radiation (41%), with most radiation delivered to chest/mantle fields (81%). Survivors reported a diversity of radiation- and chemotherapy-related sequelae, including thyroid dysfunction, speaking and/or swallowing changes, pulmonary fibrosis/pneumonitis, heart disease, chronic fatigue, neurocognitive decline, neuropathy, sexual changes, and secondary breast cancers. Few reported receipt of previous survivorship information. Most reported management/comanagement by an oncology specialist after active treatment; however, a shift to management by primary care provider alone was observed as a trend over time in follow-up. Sixty-six percent of users who responded to a follow-up survey reported that they intend to share the SCP with their health care team. CONCLUSION Survivors of lymphoma, many of whom are free of disease, report a substantial burden of late and long-term adverse effects, suboptimal delivery of survivorship information, and transitions of care in follow-up in which fragmented systems and/or poor communication may contribute to unmet survivor needs. Multiple opportunities thus exist for which SCPs may be used to improve awareness regarding survivorship and associated adverse effects in addition to communicating follow-up care plans between survivors and treatment teams.

Five-year Long-term Outcomes of Stereotactic Body Radiation Therapy for Operable Versus Medically Inoperable Stage I Non–small-cell Lung Cancer: Analysis by Operability, Fractionation Regimen, Tumor Size, and Tumor Location

Background: Stereotactic body radiation therapy (SBRT) is standard for medically inoperable stage I non–small‐cell lung cancer (NSCLC) and is emerging as a surgical alternative in operable patients. However, limited long‐term outcomes data exist, particularly according to operability. We hypothesized long‐term local control (LC) and cancer‐specific survival (CSS) would not differ by fractionation schedule, tumor size or location, or operability status, but overall survival (OS) would be higher for operable patients. Patients and Methods: All consecutive patients with stage I (cT1‐2aN0M0) NSCLC treated with SBRT from June 2009 to July 2013 were assessed. Thoracic surgeon evaluation determined operability. Local failure was defined as growth following initial tumor shrinkage or progression on consecutive scans. LC, CSS, and OS were calculated using Cox proportional hazards regression. Results: A total of 186 patients (204 lesions) were analyzed. Most patients were inoperable (82%) with Eastern Cooperative Oncology Group performance status of 1 (59%) or 2 (26%). All lesions received biological effective doses ≥ 100 Gy most commonly (94%) in 3 to 5 fractions. The median follow‐up was 4.0 years. LC at 2 and 5 years were 95.6% (95% confidence interval, 92%‐99%) and 93.7% (95% confidence interval, 90%‐98%), respectively. Compared with operable patients, inoperable patients did not have significant differences in 5‐year LC (93.1% vs. 96.7%; P = .49), nodal failure (31.4% vs. 11.0%; P = .12), distant failure (12.2% vs. 10.4%; P = .98), or CSS (80.6% vs. 91.0%; P = .45) but trended towards worse OS (34.2% vs. 45.3%; P = .068). Tumor size, location, and fractionation did not significantly influence outcomes. Conclusions: SBRT has excellent, durable LC and CSS rates for early‐stage NSCLC, although inoperable patients had somewhat lower OS than operable patients, likely owing to greater comorbidities.

First Ever Use of Proton Stereotactic Body Radiation Therapy Delivered with Curative Intent to Bilateral Synchronous Primary Renal Cell Carcinomas

Limited therapeutic options exist for inoperable bilateral kidney tumors. We report the first ever use of proton therapy to treat primary renal cell carcinoma (RCC) and the first report of proton stereotactic body radiation therapy (SBRT) for RCC in an inoperable patient with synchronous RCCs treated with proton SBRT. The patient is a 47-year-old 450-pound female with multiple medical comorbidities, including Stage 3 chronic kidney disease (CKD), who was found to have bilateral renal masses during work-up for cellulitis and sepsis. Following resolution of her sepsis, subsequent cross-sectional imaging demonstrated interval growth of the left renal mass to 4.4 x 4.8 cm and the right renal mass to 2.0 x 2.6 cm. Bilateral biopsies were performed, with pathology revealing Furhman Grade 1-2 clear cell RCC on both sides. A customized SBRT plan delivered a total dose of 3,000 cGy in five fractions to the bilateral kidneys every other day using proton beam therapy. The patient experienced no grade > 1 acute adverse toxicities from proton therapy, and now at one year after treatment, she has had no clinical symptoms of late radiation-induced toxicities. Although a marginal decline in post-treatment glomerular filtration rate (GFR) was observed (baseline 34 mL/min/1.73m2, one-year post-SBRT 29 mL/min/1.73m2), the patient remains asymptomatic and without a requirement for intervention. In presenting a case in which proton SBRT was performed safely and effectively for a medically complex patient with inoperable synchronous bilateral RCC, we suggest that proton therapy is a promising therapeutic approach for even unilateral primary RCC where preservation of renal function is of importance and should be considered for medically inoperable patients. Further experience is needed to determine the optimal dose and fractionation regimen for renal SBRT with proton therapy.

Abstract CT120: Radiotherapy in pediatric patients with atypical teratoid rhabdoid tumor of the central nervous system

Atypical teratoid/rhabdoid tumor (ATRT) of the CNS is a rare, highly malignant tumor of early childhood. Current protocols favor multimodality treatment, but practice guidelines differ with regard to radiotherapy. The aim of this study was to evaluate outcomes and prognostic factors in pediatric ATRT receiving multimodality treatment including postoperative radiation. Pediatric subjects with CNS ATRT treated at our institution between 2000 and 2014 were evaluated. Kaplan Meier method was used to estimate progression free survival (PFS) and overall survival (OS) over time and log-rank tests were used to examine associations of demographic and treatment factors with PFS and OS. 20 pediatric subjects (median age 23.5 months; range 4-99 months) with CNS ATRT treated at our institution between 2000 and 2014 were retrospectively evaluated. All underwent surgical resection, adjuvant radiotherapy, and aggressive multi-agent chemotherapy. PFS at 1-year was 63.3% (95% CI, 38.1% - 80.6%) and 2-years was 46.1% (95% CI, 22.9% - 66.5%). OS at both 1- and 2-years was 73.0% (95% CI, 46.7% - 87.8%). Infratentorial disease, lack of metastatic disease at diagnosis, and gross total tumor resection were identified as beneficial prognostic factors in PFS and OS. Progressive disease after radiation was identified as a poor prognostic factor in OS. Radiation modality (proton versus x-ray) did not affect disease-related outcomes. Modern treatment for ATRT with aggressive multimodality therapy including radiotherapy results in a significant portion of subjects with long-term disease control. Prognosis appears to be improved in subjects with localized, completely resected disease. Citation Format: Melissa Frick, Jane Minturn, Yi-Mei Li, Christine Hill-Kayser. Radiotherapy in pediatric patients with atypical teratoid rhabdoid tumor of the central nervous system. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT120.