V. Gupta

Intensity-modulated radiation therapy (IMRT) for inoperable non-small cell lung cancer: The Memorial Sloan-Kettering Cancer Center (MSKCC) experience

INTRODUCTION Intensity-modulated radiation therapy (IMRT) is an advanced treatment delivery technique that can improve the therapeutic dose ratio. Its use in the treatment of inoperable non-small cell lung cancer (NSCLC) has not been well studied. This report reviews our experience with IMRT for patients with inoperable NSCLC. METHODS AND MATERIALS We performed a retrospective review of 55 patients with stage I-IIIB inoperable NSCLC treated with IMRT at our institution between 2001 and 2005. The study endpoints were toxicity, local control, and overall survival. RESULTS With a median follow-up of 26 months, the 2-year local control and overall survival rates for stage I/II patients were 50% and 55%, respectively. For the stage III patients, 2-year local control and overall survival rates were 58% and 58%, respectively, with a median survival time of 25 months. Six patients (11%) experienced grade 3 acute pulmonary toxicity. There were no acute treatment-related deaths. Two patients (4%) had grade 3 or worse late treatment-related pulmonary toxicity. CONCLUSIONS IMRT treatment resulted in promising outcomes for inoperable NSCLC patients.

Patterns of Local and Nodal Failure in Malignant Pleural Mesothelioma After Extrapleural Pneumonectomy and Photon-Electron Radiotherapy

Introduction: Multimodality therapy including extrapleural pneumonectomy (EPP), chemotherapy, and radiotherapy (RT) is often recommended for fit patients with early stage malignant pleural mesothelioma. Planning RT after an EPP is difficult due to the large target area, the high doses required to prevent recurrence, and the proximity of critical structures. We studied patterns of local and nodal recurrence in patients treated at our institution with EPP and RT, and whether advanced treatment planning techniques, such as intensity modulated radiotherapy (IMRT), could have been of potential benefit. Methods: From 1993 to 2008, 86 patients with malignant pleural mesothelioma underwent EPP followed by hemithoracic RT (median dose: 54 Gy). The RT technique included a combination of photons and electrons to maximize dose to the target, whereas minimizing dose to normal tissues. After treatment, patients were followed with serial imaging and patterns of local and nodal failure were studied. Results: Median follow-up time for 78 analyzed patients was 17 months. Eight percent were in stage I, 35% stage II, 55% stage III, and 2% stage IV. Ten percent of all patients developed late grade 3 pulmonary toxicity and no patient died of RT. Fifteen patients failed in local and/or nodal sites and did not have a distant component to their failure pattern. Of these 15 patients, 10 failed in regions of dose inhomogeneity and could have possibly benefited from IMRT. Conclusions: The photon-electron technique was tolerable, but IMRT may provide better target coverage in some patients. IMRT’s advantages must be balanced against the increased risk of fatal pulmonary toxicity.

Human Papilloma Virus Positive Oropharyngeal Squamous Cell Carcinoma in the Elderly

BACKGROUND/AIM Elderly patients with HPV+ oropharyngeal cancer (OPC) represent an understudied cohort of the HPV epidemic. We aimed to investigate the clinical presentation, treatment tolerability and outcomes in patients ≥65 years old with HPV+ OPC. PATIENTS AND METHODS We identified all patients aged 65 and older treated at our Institution with HPV+ OPC and analyzed patient demographics, disease characteristics, treatment modalities, toxicities, treatment failures, and survival. Charlson comorbidity index was calculated for each patient. RESULTS 43 patients were identified with a mean age of median age was 70.0 (range 65-86). The mean Charlson comorbidity index score for the cohort was 5.2. In total, 72.1% of patients received what was considered standard-of-care based on stage and pathological features. Nine point three percent of patients required RT-related treatment breaks with the majority being women (75%). Three-year actuarial overall survival was 85.5% (95% CI: 71.4%-100%) and 3-year disease-free survival was 67.3% (95% CI: 49.7-91.0%). CONCLUSION This study presented one of the largest series to date evaluating HPV-related OPC in patients ≥65. Elderly individuals with HPV+ OPC have favorable overall survival with high treatment tolerability independent of Charlson co-morbidity score. Elderly patients should be considered for stage-appropriate care with omission of specific therapies based on absolute contraindications and patient preference, but not assumptions regarding tolerability.

Robotic Surgery plus Chemo-Radiation Therapy

B 34 fractions over 6 weeks B Volumetric Arc Therapy 2) Given 1 mm margin and multiple nodal involvement, I offer: adjuvant RT, rather than re-excision of primary, given the neck warrants adjuvant treatment regardless B 60 Gy primary surgical bed and site of nodal disease B 56 Gy uninvolved perturbed neck B 54 Gy unperturbed ipsilateral neck (RP nodes & level V) B 30 fractions over 6 weeks B No justification for de-escalation of PORT at this point in time 3) I continue to offer these patients adjuvant chemo-RT, making them aware of the potential “overkill” associated with combined modality treatment for minor extracapsular extension in HPVþOPC cisplatin (100 mg/m) weeks 1 & 4 and 60 Gy over 6 weeks B patients made aware of the potential use of weekly low-dose cisplatin, but limited evidence