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Aim To report outcomes of Stereotactic Body Radiotherapy (SBRT) for head and neck skin cancer (HNSC) patients treated at a high-volume center. Materials A retrospective review of HNSC SBRT patients from 2012 to 2019 was conducted. Kaplan–Meier method was used to estimate local control (LC), locoregional control (LRC) outside of SBRT field, overall survival (OS), progression-free survival (PFS) and late toxicity (LT). Univariate and multivariate analyses were performed. Grade 3-4 acute and late toxicities were reported by the Common Terminology Criteria for Adverse Events v5.0. Results One hundred and six medically unfit HNSC patients (112 lesions) were included. Median follow-up was 8 months. Median patient age at diagnosis was 86 years (range: 56–102 years). The majority of patients had advanced disease (overall stage III-IV [n = 90, 85%]) with median gross tumor volumes (GTV) of 31 cm3 (range: 17–56 cm3). Treated sites were: primary (n = 51), nodal (n = 47) or primary plus nodal (n = 8). SBRT doses ranged from 32-50 Gy delivered twice weekly in 4–6 fractions to the gross tumor volume (GTV). One and 2-year LC rates were 78% (69–88) and 67% (53–82), respectively. One-year LRC outside of SBRT field, OS, PFS and LT rates were 72% (62–84), 53% (43–65), 52% (40–62), and 7% (2–17), respectively. Thirty-three patients (31%) developed acute grade ≥ 3 treatment-related toxicity, most commonly dermatitis (n = 31). Nine patients (8%) experienced late grade ≥ 3 toxicity, including 7 grade 3 fibrosis, 1 grade 3 bone radionecrosis and 1 grade 4 skin ulceration. No treatment-related deaths (grade 5) were observed. Conclusion SBRT provides durable disease control with acceptable toxicity for medically unfit high-risk HNSC patients unable to undergo standard of care curative treatment approaches.

Background Stereotactic body radiotherapy (SBRT) is increasingly used to treat oligometastatic disease (OMD), but the effect of metastasis timing on patient outcomes remains uncertain. Methods An international database of patients with OMD treated with SBRT was assembled with rigorous quality assurance. Early versus late metastases were defined as those diagnosed ≤24 versus >24 months from the primary tumor. Overall survival (OS), progression‐free survival (PFS), and incidences of wide‐spread progression (WSP) were estimated using multivariable Cox proportional hazard models stratified by primary tumor types. Results The database consists of 1033 patients with median follow‐up of 24.1 months (0.3–104.7). Late metastatic presentation (N = 427) was associated with improved OS compared to early metastasis (median survival 53.6 vs. 33.0 months, hazard ratio [HR] 0.59, 95% confidence interval [CI]: 0.47–0.72, p, Despite the increasing utilization of stereotactic body radiotherapy (SBRT) for patients with oligometastasic disease (OMD), prognostic and predictive factors for this treatment modality are not well understood. In this analysis of a large, multi‐institutional database of SBRT for OMD, the timing of metastatic presentation is a significant prognostic factor, as patients with late metastasis (>24 months from cancer diagnosis) have lower risk of widespread progression and death after SBRT.

Background A single institutional experience of stereotactic body radiation therapy (SBRT) to medically unfit patients with unresectable head and neck cancers (HNCs). Methods A retrospective review of HNC patients undergoing SBRT was undertaken from 2011 to 2016 for fractionation ranges between 35 and 50 Gy in 4 to 6 fractions. Results One hundred and fourteen patients with 117 SBRT courses were included with mean follow-up of 10.5 months. The cohort consisted of previously untreated primary HNC (n = 48), recurrent never irradiated HNC (n = 19), oligometastatic (n = 17) non-HNC primaries and previously irradiated HNC (n = 33). Local control (LC) at 12 months and median progression free survival was 85.8%, 78.2%, 85%, 78.9% (P = .86) and 23.7, 14.8, 10.5 and 7.8 months (P = .04) respectively. Only one patient had an acute grade 4 toxicity, two patients had grade 4 late toxicities. Conclusions HNC SBRT is an effective treatment for frail patients where longer LC is relevant but are unable to tolerate protracted radiation schedules.

PURPOSE/OBJECTIVE(S) Treatment of oligometastatic disease with SBRT has shown the potential to improve disease control and survival in trials largely focused on lung and prostate cancer. Outcomes in other sites, such as head and neck cancers (HNC) are poorly defined. Here we report the results of a multi-institutional cohort of oligometastatic HNC patients receiving SBRT. MATERIALS/METHODS Data on HNC patients treated between 2008 and 2016 was extracted from an international consortium of six high volume SBRT centers. Patients were considered oligometastatic if they had 5 or fewer extracranial metastases. The risk of local recurrence (LR) and widespread progression (WSP, defined as 6 or more metastatic sites) was estimated with competing risks analysis. Overall survival (OS) and progression-free survival (PFS) were estimated with the Kaplan-Meier method. Univariable and multivariable regression analysis (MVA) was used to determine the relationship between covariates and the main endpoints. RESULTS Forty-two patients harboring 84 metastases from mucosal head and neck cancer were included. The median age was 64 and most patients were male (83%). The median follow up was 18.2 months. The most common primary site was the oropharynx (43%). Most patients had 1 or 2 metastases (78.6%). Metastatic sites treated with SBRT were mostly lung (50%) and bone (35.7%). Presentation was synchronous in 11 patients (26.2%), early metachronous (within 24 months of diagnosis, 57%) and late metachronous in 7 patients (> 24 months from diagnosis, 16.7%). The majority of patients (88%) had no systemic therapy prior to SBRT. SBRT dose and fractionation ranged from 20-28 Gy/1fx to 50 Gy in 5-10fx. The median biologic equivalent dose (BED10) was 100 Gy. The local control rate was 80% at 1 year and 66% at 2 years. The median PFS was 4.7 months. The median overall survival (OS) was 23.3 months. Improved local control on MVA was seen with patients who had a maximum point BED greater than the median (HR = 0.31; 95% CI: 0.10-0.91, P = 0.03). Disease burden significantly correlated with PFS, with larger combined PTV volumes for all metastases greater than the median of 48cc having worse PFS on MVA (HR = 2.99; 95% CI: 1.58-5.66, P < 0.001). The risk of WSP at 12 and 24 months was 31.7% and 48.3%, respectively. There was a trend towards lower rates of WSP for patients who presented with late metachronous disease versus all others (HR = 0.22; 95% CI: 0.03-1.82, P = 0.16). Severe toxicity was rare, with one patient developing a grade 3 brachial plexus injury after spine SBRT and one patient with grade 3 pneumonitis after lung SBRT. CONCLUSION Patients undergoing SBRT for oligometastatic head and neck cancer have favorable local control and overall survival, however, PFS remains short. Patients with a late metachronous presentation may have more favorable biology. Future study should focus on whether subsets of patients such as those with synchronous or early metachronous disease may benefit from pre-SBRT systemic therapy.

Purpose/Objective(s) In recent years, stereotactic body radiotherapy (SBRT) has emerged as an effective local treatment for oligometastatic cancers. However, it has been suggested that colorectal cancers may represent a more radioresistant histology, even to the high doses used in SBRT. Here, we report local recurrence rates, progression free-survival, and overall survival of patients with oligometastatic CRC treated with SBRT using a large multi-institutional data-base. Materials/Methods We collected data retrospectively from six cancer centers with a high volume of SBRT treatments from Jan 1 2008 to December 31, 2016. Our primary outcome was local recurrence while secondary outcomes included overall survival (OS), local recurrence free survival, progression free survival, oligo-progression, and widespread progression. Time-to event outcomes were estimated using the Kaplan-Meier method. Univariable regression analysis was performed to determine the relationship between patient, tumor and treatment variables and outcomes. Variables significant on univariable screen were entered into a multivariable model. All analysis was performed in R (R Foundation for Statistical Computing, version 4.0.2) Results We identified 235 patients with a total of 381 oligometastatic CRC lesions that were treated with SBRT. The mean age was 70.7 ± 12.2 years, 58% of patients were male with a median follow-up of 25.5 months. The most common site of metastasis was the lung (n = 133, 56.6%) with a total of 239 (62.7%) lesions. The median time to local recurrence was not reached with the 1- and 5-year local recurrence rate was 13.6% and 44.3% respectively. The median OS was 49 months with a 2-and 5-year probability of 76.1% and 35.9% respectively. On multivariable analysis, a BED10 of ≥100 Gy (HR 0.67, 95% CI 0.45-0.99) and the presence of lung (HR 0.53, 95% CI 0.34-0.82) or lymph node metastasis as opposed to liver metastasis (HR 0.31, 95% CI 0.13-0.74) were associated with improved local control. Larger total PTV size (≥17.5cc) was associated with worse overall survival (HR 2.62, 95% CI 1.45-4.72), progression free survival (HR 2.01, 95% CI 1.39-2.90) and widespread progression (HR = 2.82, 95% CI: 1.63-4.88). Use of prior systemic therapy before SBRT was also adversely associated with widespread progression (HR = 1.90, 95% CI: 1.22-2.95). Conclusion This large multi-institutional analysis found that the use of SBRT for oligometastatic colorectal cancer resulted in favorable overall survival. However, local recurrence is appreciably lower than what has historically been demonstrated in other cancer primary sites. These results suggest that an increase in BED should be considered if feasible and safe, in order to optimize local control. Increased overall PTV size may also be an indicator for the need for systemic therapy in addition to SBRT.

Background We hypothesized that the total volume of metastases at initial oligometastatic (OM) presentation to stereotactic body radiation therapy (SBRT) is an important prognostic factor that can refine the definition of OM disease. Methods Patients with extracranial oligometastatic cancer (≤5 lesions) treated with SBRT were included in an international multi‐institutional database. Multivariable Cox and competing risks regression models were used to determine the relationship between distant progression‐free survival (DPFS), widespread progression (WSP), and overall survival (OS) with the total planning target volume (PTV) at initial OM presentation to SBRT. All models were adjusted for histology, pre‐SBRT systemic therapy, osseous‐only lesions, and number of metastases. Results In total, 961 patients were included. The median follow‐up was 24.4 months (IQR: 13.8–37.5). Total PTV had a significant effect on DPFS in the first 18 months after SBRT and was most profound in the first 6 months, when each twofold increase in total PTV conferred a 40.6% increased risk of distant progression (p, This large international, multi‐institutional series of SBRT to extracranial oligometastases demonstrates total volume of metastatic lesions as a strong, independent prognostic factor for cancer outcomes. This metric can redefine oligometastatic disease beyond number of lesions and refine patient selection for an increasingly important treatment paradigm.

Aims We report on the first prospective series of patient-reported quality of life (QoL) following stereotactic body radiation therapy (SBRT) for primary kidney cancer. Materials and methods Patients were treated on a multi-institutional prospective cohort study with 30–42 Gy SBRT in three or five fractions. QoL assessments were carried out using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-15 Palliative (EORTC-QLQ-C15-PAL), the Functional Assessment of Cancer Therapy-Kidney Symptom Index-19 (FACT FKSI-19) and the EuroQol-5D-3L tools at baseline, 1 week, and 1, 3 and 6 months post-treatment. QoL over time was analysed using linear mixed modelling, pairwise and anchor-based analyses. Results Twenty-eight patients were included. No significant reduction in any QoL metric was observed on repeated measures. However, a trend to reduced EORTC global QoL and fatigue was observed at 1 week, with improvement over time in other symptom scores such as pain, appetite and nausea. On pairwise analysis, there were statistically significant reductions in global QoL at 1 week (with subsequent recovery) and dyspnoea at 6 months post-SBRT. Trends to improved pain, appetite and nausea were observed following SBRT. Less than half of patients reported stable or better EORTC global QoL at 1 week. For all other QoL and symptom scales, most patients had reported stable or better scores at all times, with a slight proportional improvement in emotional functioning, nausea, fatigue, pain and appetite, and a slight worsening of physical functioning and dyspnoea over time. Conclusions SBRT results in well-preserved QoL in the weeks to months following treatment for primary kidney cancer.

Introduction Despite treatment advances, the prognosis of locally advanced pancreatic cancer is poor. Treatment remains varied and includes systemic and radiotherapy (RT). Stereotactic body radiotherapy (SBRT), highly conformal high-dose RT per fraction, is an emerging treatment option. Materials and methods We performed a single-institution retrospective review of patients with pancreatic adenocarcinoma treated with SBRT from 2015-2017. The median dose was 27 Gy (range: 21-36 Gy) in three fractions. Endpoints included local progression (RECIST 1.1; Response Evaluation Criteria in Solid Tumors 1.1), distant metastasis, overall survival, and toxicity. Results Forty-one patients were treated, with a median follow-up of eight months. Patients who received SBRT had unresectable (49%), metastatic (17%), or borderline resectable (7%) disease, declined surgery (17%), medically inoperable (7%), or developed local recurrence following the Whipple procedure (2%). The six-month and one-year rates of local progression-free survival, distant metastasis-free survival, and overall survival were 62% and 55%, 44% and 32%, and 70% and 49%, respectively. Five patients (12%) experienced seven late gastrointestinal (GI) grade 3 events. Conclusion SBRT may be considered a treatment option to achieve local control of pancreatic cancer and is associated with a modest risk of severe late GI toxicities. Systemic therapies remain important, given the proportion of patients who develop distant metastases.

Objectives The purpose of this study was to review the clinical outcomes following the use of stereotactic body radiotherapy (SBRT) in patients with metastatic non-small-cell lung cancer (NSCLC) from a large academic institution. Materials and methods Metastatic NSCLC patients treated with extracranial SBRT were identified from an institutional database. Treatment indications were: (1) oligometastases, (2) oligoprogression, and (3) local control of dominant tumors. Endpoints included overall survival (OS), progression-free survival (PFS), time to starting/changing systemic therapy (SCST), and local failure (LF). Univariate and multivariable analyses were performed to look for predictive factors. Results 108 patients with 165 tumors were treated. SBRT was delivered for oligometastases in 66 patents, for oligoprogression in 20 patients, and for local control in 22 patients. Median OS and PFS for all patients were 27.3 months and 4.4 months, respectively, with treatment indication being the only predictive factor on multivariable analysis (patients with oligometastases having the highest median OS and PFS of 39.3 months and 7.6 months respectively). Cumulative incidence of SCST was only 21.5% at 1 year after SBRT, with larger tumor size and positivity for EGFR/ALK mutation being predictive of higher rates of SCST on multivariable analysis. LF was 15.6% at 1 year, with larger tumor size and exposure to previous systemic therapy being predictive of higher rates of LF on multivariable analysis. Conclusion Patients treated with SBRT for oligometastases have better OS and PFS than those treated for oligoprogression or for local control of dominant tumors. Use of SBRT may delay the need for SCST. Larger tumors and previous exposure to systemic therapy were predictive of higher rates of LF.

PURPOSE/OBJECTIVE(S) The definition of oligometastatic (OM) disease has largely focused on the number of metastatic lesions. Here, we investigate the total volumetric burden of metastases at initial OM presentation as an independent prognostic factor for distant progression free survival (DPFS), widespread progression (WSP, i.e., > 5 new lesions), and overall survival (OS) in patients treated with SBRT. MATERIALS/METHODS Patients with oligometastatic cancer treated with SBRT at 6 international institutions from 2007 - 2016 were retrospectively reviewed. Patients were included if they had 1) five or fewer metastases, 2) no history of brain metastases, 3) curative treatment for primary disease, and 4) SBRT to all known metastases. Multivariable Cox regression models were used to determine the relationship between DPFS and OS with the total planning target volume (PTV) at initial OM presentation. The relationship between WSP and total PTV was determined using multivariable competing risks regression. All models were adjusted for the potential confounders of histology, pre-SBRT systemic therapy, osseous-only vs. visceral lesions, and number of metastases. RESULTS In total, 961 OM patients were included. The median follow-up was 24.4mo (IQR: 13.8-37.5). The most common primary histologies were NSCLC (25.9%), colorectal (22.0%), prostate (13.3%), and breast (7.9%). The majority of patients (59.4%) had a solitary oligometastasis, while 22.6%, 9.6%, 5.5%, and 2.9% had 2, 3, 4, or 5 lesions, respectively. Two-thirds (65.8%) did not have pre-SBRT systemic therapy, and 28.3% had only osseous lesions. The median total PTV was 40.0cc (IQR: 19.7-85.0). The median DPFS, time to WSP, and OS were 15.1, 43.5, and 44.7mo, respectively. Modeling total PTV using restricted cubic splines revealed significant non-linear effects, and log-transformation was optimal to account for this non-linearity. Total PTV had a significant effect on DPFS in the first 18mo after SBRT and this was most profound in the first 6mo, when each doubling of total PTV conferred a 40.6% increased risk of distant progression (P < 0.001). Similarly, each total PTV doubling increased the risk of WSP by 45.4% in the first 6mo (P < 0.001). Total PTV had a significant effect on OS in the first 2yrs after SBRT, with each PTV doubling increasing the risk of death by 60.7% during the first 6mo (P < 0.001) and by 34.6 % thereafter (P < 0.001). Exploratory GTV analysis, where complete data was available for 76.1% of patients due to variability in contouring GTV vs. CTV, confirmed the PTV-based observations. CONCLUSION This large multi-institutional series demonstrates the strong impact of total volumetric burden of metastases at initial OM presentation on the risk of distant and widespread progression and OS. We propose that total volume of metastatic lesions may have prognostic merit beyond number of metastases in identifying OM patients who would benefit most from systemic therapy in addition to local metastasis-directed therapy.

PURPOSE/OBJECTIVE(S) Multiparametric magnetic resonance imaging (mpMRI) is increasingly being used in high dose rate (HDR) brachytherapy treatment planning. Its enhanced soft tissue contrast over conventional computed tomography increases the ability to identify the dominant intraprostatic lesion (DIL) and enables focal boosting using HDR brachytherapy. This can have important implications for adjacent organs at risk. We therefore investigated the acute and late toxicities reported within our institutional experience with this approach. MATERIALS/METHODS We compiled 4 cohorts of prostate cancer patients treated with mpMRI dose painted HDR brachytherapy (either as a boost or as monotherapy on clinical trial) between December 2014 and October 2018. Salvage brachytherapy was excluded. Three of the cohorts were from prospective clinical trials (MARS, HDR monotherapy and SPARE). For the MR-HDR boost cohort, pertinent demographic, clinical and dosimetric information were extracted from patients' medical records. Descriptive statistics were used to summarize baseline data. Toxicities experienced were coded using the Common Terminology Criteria for Adverse Events (CTCAE) version 3.0. The Nelson-Aalen estimator method using 95% confidence intervals was used to assess the cumulative incidence of biochemical failure (BCF; using the Phoenix Failure definition) and the cumulative incidences of grade 2 or higher toxicity. RESULTS 144 patients with a mean age (65.6 ± 6.7 years), follow-up (55.7 ± 15.0 months) and baseline PSA (9.7 ± 8.3 ng/mL), with predominantly cT2a (32.6%) and Gleason 7 (3+4; 62.0%) disease, were included in the final analysis. Fifteen patients treated with MR-HDR boost were followed elsewhere so no toxicity data were available at time of analysis. All risk groups were represented: low (10.4%), favorable (27.8%) and unfavorable intermediate (36.8%), and high (25.0%). 25/137 (18%) experienced BCF with cumulative incidence rates of 20.6% at 5-years. A total of 41/129 (32%) patients experienced any grade 2+ GU (1 G3) and 7/129 patients (5.4%) experienced any grade 2+ GI (0 G3) toxicity. The cumulative incidence rates at 5-years were 33.2% for GU and 5.7% for GI, respectively. Neither BCF or toxicity (GU or GI) was significantly different between treatment groups. CONCLUSION Dose escalation to the DIL using mp-MRI dose painted HDR brachytherapy appears to be feasible, safe and well-tolerated. Further follow-up and investigation are warranted to determine whether MR-HDR improves outcomes compared to standard non-MR-HDR brachytherapy.

To assess the association between colorectal cancer (CRC) histology, dose, and local failure (LF) after stereotactic ablative radiation therapy (SABR) for pulmonary metastases, and to describe subsequent cancer progression, change of systemic therapy (CST), survival, and their association with treatment indications.From a prospective SABR cohort, 180 pulmonary metastases in 120 patients were identified. Treatment indications were single metastasis, oligometastases, oligoprogression, and dominant areas of progression. Doses of 48 to 52 Gy/4 to 5 fractions were delivered. Since 2010 the dose for peripheral CRC metastases was increased to 60 Gy/4 fractions. Cumulative incidence function (CIF) was used to report LF, progression probability, and CST. The Kaplan-Meier method estimated overall survival (OS). Univariate and multivariable analyses to assess variable associations were conducted.Median follow-up was 22 months (interquartile range, 14-33 months). At 24 months, the CIF of LF was 23.6% (95% confidence interval [CI] 15.1%-33.3%) and 8.3% (95% CI 2.6%-18.6%), respectively, for CRC and non-CRC metastases (P.001). This association remained significant after adjusting for confounders (subdistribution hazard ratio [SHR] 13.6, 95% CI 4.2-44.1, P.001). Among CRC metastases, 56 and 45 received60 Gy and 60 Gy, respectively. Delivering 60 Gy was independently associated with a lower hazard of LF (SHR 0.271, 95% CI 0.078-0.940, P=.040). At 12 months the CIF of progression was 41.67% (95% CI 21.69%-60.56%), 42.51% (95% CI 29.09%-55.29%), 62.96% (95% CI 41.25%-78.53%), and 78.57% (95% CI 42.20%-93.48%), respectively, for patients treated for single metastasis, oligometastases, oligoprogression, and dominant area of progression (P.001). A CST was observed, respectively, in 4 (17%), 17 (31%), 12 (44%), and 10 (71%) patients with a median time of 13.1, 11.1, 8.4, and 8.4 months.Colorectal cancer lung metastases are associated with a higher hazard of LF and require higher SABR doses. Outcomes for patients with oligometastases and oligoprogression treated with SABR seem favorable. Prospective clinical trials are needed to confirm these benefits.

This case series reports overall progression-free survival, widespread progression outcomes, and prognostic survival factors from a pooled data set of 1033 patients with oligometastasis treated with stereotactic body radiotherapy., Key Points Question What are survival outcomes and factors specific to patients with oligometastasis (OM) treated with stereotactic body radiotherapy? Findings In the largest international OM case series to date (1033 participants), the median overall survival was prolonged at 44.2 months and statistically significantly associated predominantly with primary tumor type and a metachronous presentation more than 24 months since initial OM diagnosis. The median progression-free survival was 12.9 months; however, a substantial proportion of patients relapsed in an oligoprogressive pattern that was amenable to repeat local therapy. Meaning Findings of this study suggest that patients with OM disease have long-term overall survival and modest progression-free survival; a metachronous presentation more than 24 months since diagnosis is favorable., Importance The outcomes and factors that influence survival in patients with oligometastasis (OM) are not well understood and have not been well described in large-scale studies. Objective To evaluate overall progression-free survival (PFS), widespread progression (WSP) outcomes, and survival factors from a pooled data set of 1033 patients with OM treated with stereotactic body radiotherapy (SBRT). Design, Setting, and Participants Case series from January 1, 2008, to December 31, 2016. The dates of analysis were April 2019 to May 2020. The setting was multi-institutional tertiary care hospitals. Participants were consecutive patients with 5 or fewer extracranial OMs whose primary tumor was treated curatively. Exposure Definitive SBRT. Main Outcomes and Measures Overall survival (OS), progression-free survival, rate of WSP, patterns of failure, and factors altering OS. Results In the largest international OM case series to date (1033 participants) (mean age, 68.0 years [range, 18.0-94.3 years]; 601 [58.2%] men), 1416 SBRT courses were delivered to patients with 1 OM (596 [57.7%]), 2 OMs (245 [23.7%]), 3 OMs (105 [10.2%]), 4 OMs (55 [5.3%]), and 5 OMs (32 [3.1%]). The median follow-up was 24.1 months (range, 0.3-104.7 months), and the median OS was 44.2 months (95% CI, 39.2-48.8 months). The median PFS was 12.9 months (95% CI, 11.6-14.2 months), and the median time to WSP was 42.5 months (95% CI, 36.8-53.5 months). The OS rates were 84.1% (95% CI, 81.7%-86.2%) at 1 year, 56.7% (95% CI, 53.0%-60.2%) at 3 years, and 35.2% (95% CI, 30.1%-40.3%) at 5 years. The 3-year OS, PFS, and WSP rates were 56.7% (95% CI, 53.0%-60.2%), 23.0% (95% CI, 20.2%-25.9%), and 45.2% (95% CI, 41.4%-48.9%), respectively. The 5-year OS, PFS, and WSP rates were 35.2% (95% CI, 30.1%-40.3%), 14.8% (95% CI, 11.9%-17.9%), and 54.5% (95% CI, 49.8%-59.2%), respectively. At the time of first progression, 342 patients (33.1%) had recurrence of OM disease, and 230 patients (22.3%) underwent subsequent ablative therapies to all known metastatic sites. Multivariable analyses identified primary tumor type (hazard ratio [HR], 3.73; 95% CI, 1.75-7.94; P

Background and purpose To review the clinical outcomes following the use of stereotactic body radiotherapy (SBRT) in patients with metastatic colorectal cancer (mCRC) from a large academic institution. Materials and methods Patients with mCRC treated with extracranial SBRT between 2008 and 2016 were identified from an institutional database. Treatment indications were oligometastases, oligoprogression, and local control of dominant tumors. Endpoints included local progression (LP), overall survival (OS), progression-free survival (PFS), and cumulative incidence of starting or changing systemic therapy (SCST). Univariate and multivariable analyses (MVA) were performed to identify predictive factors. Results One hundred and sixty-five patients (262 lesions treated) were included. The 2-year cumulative incidence of LP was 23.8%. Lower SBRT doses and tumor location in the liver were significant predictors of LP on MVA. Median OS was 49.3 months, 19.3 months, and 9.0 months for oligometastases, oligoprogression, and local control of dominant tumors, respectively. Primary tumor not in situ, smaller tumors, fewer lines of previous systemic therapy, lower CEA, and oligometastases treatment indications were significant predictors of higher OS on MVA. For the entire cohort, median PFS was 9.9 months, while oligometastatic patients had a median PFS of 12.4 months. 2-year cumulative incidence of SCST was 41.7%. Conclusions Survival outcomes are favorable after SBRT for mCRC patients. A significant proportion of patients did not have a change in systemic therapy after SBRT. Higher doses are required to obtain the best local control. Efforts should be made to better optimize SBRT delivery for liver metastases given their higher local failure rate.

Purpose: The incidence of human papillomavirus (HPV)-related head and neck cancer now exceeds the incidence of HPV-related cervical cancer in Canada. A study conducted at our institution identified that patients were not provided with sufficient information regarding HPV-positive oropharyngeal squamous cell carcinoma (HPV-OPSCC). It was also recognized that patients and their partner felt guilt and stigma about the HPV diagnosis, which had a negative impact on their intimacy. The aim of this project was to create an educational tool to address the concerns of patients and their families with HPV-OPSCC through collaboration of an interprofessional health care team and patient representatives. Methods: As part of the needs assessment, an environmental scan of patient education tools and a literature review on current evidence and management of HPV-OPSCC was conducted, resulting in pamphlets, articles and websites from various cancer centres in North America. Our institutional study was used to identify the patients’ needs including: more information on the cause of HPV, consequences to their health, and future implications to the health of their partner(s). Three virtual meetings with the development team were conducted to identify the key messages and resources suggested to be included in the educational tool. The principles of lay language and clear design was adhered to in order to ensure the educational tool was acceptable and understandable for patients and their families. Feedback was elicited from stakeholders of the Head and Neck Site Group and the Patient and Family Education Committee. Results: Discussing an HPV diagnosis on top of cancer treatment options can be overwhelming for the patient on their first visit. Furthermore, family members may not be able to accompany the patient to their appointment due to current restrictions of the COVID-19 pandemic, thereby removing an aspect of support and opportunity for family members to ask questions. This educational tool provides patients and their loved ones answers to common questions regarding HPV-OPSCC, explains how this diagnosis affects their treatment outcomes, and helps patients and family navigate the available resources and supportive services within the cancer centre and on the internet. Challenges identified throughout the project include recruiting patient representatives who felt comfortable sharing their experience, as well as obtaining feedback from a large and diverse team of busy health care professionals. Conclusions: This tool will be in the form of a printed document and will be found on the cancer centre website. Not only was the development of this tool driven by patient need, but patient engagement was prioritized with two patient representatives on the development team to collaborate on the content and design of the education tool. An evaluation of the educational tool will be conducted and may consist of tracking the number of times the educational tool was accessed and administering a survey during the patient's next appointment to determine satisfaction.

Background: In recent years, stereotactic body radiation therapy (SBRT) has become increasingly used for the management of non-spine bone metastases. Few studies have examined the radiological changes in bone metastases after treatment with SBRT and there is no consensus about what constitutes radiologic response to therapy. This article describes various changes on CT after SBRT to non-spine bone metastases in eight selected cases. Methods: A retrospective review was conducted for patients treated with SBRT to non-spine bone metastases between November 2011 and April 2014 at Sunnybrook Health Sciences Centre. A musculoskeletal radiologist identified eight illustrative cases of interest and provided a description of the findings. Results: Different radiological changes following SBRT were described, including: remineralization of lytic bone metastases, demineralization of sclerotic bone metastases, pathologic fracture, size progression and response in different lesions, as well as lung fibrosis after SBRT to a rib metastasis. Conclusions: We reviewed the radiological images of eight selected cases after SBRT to nonspine bone metastases and a number of characteristic findings were highlighted. We recommend future studies to correlate radiologic changes with clinical outcomes including pain relief, toxicity and long-term local control.

High-dose-rate brachytherapy boost plus external beam radiation therapy is an established option for intermediate-risk prostate cancer (PCa). Stereotactic body radiation therapy (SBRT) boost can potentially mimic high-dose-rate boost and could be a viable alternative. Here we report the long-term outcomes of a phase 1 dose-escalation trial of single-fraction SBRT boost.Patients had intermediate-risk PCa and were accrued to 3 different SBRT single-fraction dose-level cohorts (10 Gy, 12.5 Gy, and 15 Gy). All received supplemental radiation therapy afterwards (37.5 Gy in 15 fractions). Three gold fiducials were implanted for image guidance. Patients were simulated and treated with a foley catheter and intrarectal balloon. A T2 magnetic resonance imaging scan was used for contouring, and a cine magnetic resonance imaging scan was used to calculate patient-specific internal target volume margins. Toxicity and quality-of-life data were collected using Common Terminology Criteria for Adverse Events v3.0 and the Expanded Prostate Cancer Index Composite.30 patients were accrued, 10 in each cohort. Median follow-up was 72 months. 60% had unfavorable intermediate-risk PCa. Two patients in the 15 Gy cohort developed late grade ≥3 gastrointestinal and genitourinary toxicity, with 1 patient suffering from a grade-4 rectal fistula after a rectal ulcer was biopsied repeatedly. Two patients had biochemical failure. Median PSA nadir was 0.4 ng/mL with 10 Gy, 0.09 ng/mL with 12.5 Gy and 0.07 ng/mL with 15 Gy. Median PSA at 4 years as well as proportion achieving a nadir0.2 ng/mL improved significantly with higher doses. There was no significant change in quality of life from baseline in any of the domains, and the minimal clinically important change was not statistically different between the 3 cohorts.Other than a grade 4 toxicity, which may in part be due to repeated biopsies of a rectal ulcer, single-fraction SBRT boost was feasible and well tolerated. Larger studies are warranted to better document the outcomes of such an approach.

To determine the incidence and predictive factors of rib fracture and chest wall pain after lung stereotactic ablative radiotherapy (SABR).Patients were treated with lung SABR of 48-60 Gy in four to five fractions. The treatment plan and follow-up computed tomography scans of 289 tumours in 239 patients were reviewed. Dose-volume histogram (DVH) metrics and clinical factors were evaluated as potential predictors of chest wall toxicity.The median follow-up was 21.0 months (range 6.2-52.1). Seventeen per cent (50/289) developed a rib fracture, 44% (22/50) were symptomatic; the median time to fracture was 16.4 months. On univariate analysis, female gender, osteoporosis, tumours adjacent (within 5 mm) to the chest wall and all of the chest wall DVH metrics predicted for rib fracture, but only tumour location adjacent to the chest wall remained significant on the multivariate model (P0.01). The 2 year fracture-free probability for those adjacent to the chest wall was 65.6%. Among those tumours adjacent to the chest wall, only osteoporosis (P = 0.02) predicted for fracture, whereas none of the chest wall DVH metrics were predictive. Eight per cent (24/289) experienced chest wall pain without fracture.None of the chest wall DVH metrics independently predicted for SABR-induced rib fracture when tumour location is taken into account. Patients with tumours adjacent (within 5 mm) to the chest wall are at greater risk of rib fracture after lung SABR, and among these, an additional risk was observed in osteoporotic patients.

Aims To report local control and toxicity rates for patients treated with stereotactic body radiotherapy (SBRT) for non-spine bone metastases. Methods and materials Eighty-one patients with 106 non-spine bone metastases were treated between 2011 and 2014 and retrospectively reviewed. Indications included: oligometastases (63%), oligoprogression (17.3%), retreatment (2.4%) or other (17.3%). Cumulative incidence function was used to assess local recurrence and fracture probability. Bivariate relationships were investigated based on selected patient, tumour and dose–volume factors. Results Mean follow-up was 13 months (range, 0.25–45.6) and the median patient age was 66.4 years (range, 36–86). Most patients were male (60.5%) and the predominant histology prostate cancer (32%). Bone metastases were most commonly located in the pelvis (41.5%) and almost half sclerotic. The most common prescriptions were 30 Gy/5 (30.2%) and 35 Gy/5 (42.5%). The cumulative incidence of local recurrence at 6,18 and 24 months respectively was 4.7%, 8.3% and 13.3% with a mean time to local recurrence of 11.8 months (range, 3.9–23.4). A significant association was found between local recurrence and volume of the PTV (p = 0.02), with larger PTVs having a greater risk of local failure. Fracture was observed radiographically in the treatment volume in 9/106 (8.5%) of treated lesions and the mean time to fracture was 8.4 months (range, 0.7–32.5 months). With respect to predictors, a trend was observed for lytic lesions (p = 0.11) and female gender (p = 0.09). Conclusions The results of this study confirm that SBRT yields high rates of long-term local control for non-spine bone metastases with a low fracture risk.

To report the changes in quality of life (QoL) after stereotactic ablative radiotherapy (SABR) in patients with liver metastases (LM).A prospective cohort study was undertaken to measure the acute changes in QoL after SABR. Patients with 1-3 treated LM were eligible. Doses of 30-60 Gy in 3-5 fractions were delivered. Prospective QoL was measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires, Core 15 for Palliative Care (EORTC QLQ-C15-PAL) and liver metastases (LM21), at baseline, 1st week and last day of treatment, then 1, 6 and 12 weeks after SABR. The functional living index-emesis (FLIE) was collected at baseline, 1st week, last day and 1 week after treatment. Univariable and multivariable linear mixed modeling were performed as appropriate to assess changes in QoL over time.Sixty patients were included. The most common primary cancer was colorectal (42%). The global health score measured by QLQ-C15-PAL was significantly worse at treatment completion (p = 0.001), 1 week (p = 0.003) and 6 weeks (p = 0.002) after SABR but recovered by 12 weeks (p = 0.124). Nausea and constipation were worse at treatment completion (p 0.05) but recovered 1 week after while fatigue recovered 6 weeks post-SABR. The majority of patients reported stable QoL at 12 weeks for all domains in the C15-PAL and LM21 questionnaires.SABR offers a non-invasive mean of ablating LM with minimal impact on acute QoL.

Aims We report the outcomes of a large lung stereotactic ablative body radiotherapy (SABR) programme for primary non-small cell lung cancer (NSCLC) and pulmonary metastases. The primary study aim was to identify factors predictive for local control. Materials and methods In total, 311 pulmonary tumours in 254 patients were treated between 2008 and 2011 with SABR using 48–60 Gy in four to five fractions. Local, regional and distant failure data were collected prospectively, whereas other end points were collected retrospectively. Potential clinical and dosimetric predictors of local control were evaluated using univariate and multivariate analyses. Results Of the 311 tumours, 240 were NSCLC and 71 were other histologies. The 2 year local control rate was 96% in stage I NSCLC, 76% in colorectal cancer (CRC) metastases and 91% in non-lung/non-CRC metastases. Predictors of better local control on multivariate analysis were non-CRC tumours and a larger proportion of the planning target volume (PTV) receiving ≥100% of the prescribed dose (higher PTV V100). Among the 45 CRC metastases, a higher PTV V100 and previous chemotherapy predicted for better local control. Conclusions Lung SABR of 48–60 Gy/four to five fractions resulted in high local control rates for all tumours except CRC metastases. Covering more of the PTV with the prescription dose (a higher PTV V100) also resulted in superior local control.

Our aim was to determine the efficacy and quality of life outcomes of head and neck (HN) stereotactic body radiotherapy (SBRT) in a palliative population with significant proportions of de novo HN tumors not amenable to surgery or protracted course of curative radiotherapy (RT).A retrospective review of a prospective database identified 21 patients with 24 sites that were treated. Patients were treated with intensity modulated RT (IMRT), usually 7-9 static fields with a 2-3-mm margin from gross tumor volume to planning target volume only with no microscopic margin added. Electronic patient records and treatment plans were reviewed. Basic demographic information was collected. The EORTC QLQ-HN35 questionnaire was the tool used to collect QOL data both pre- and on-treatment fraction 5. Univariate analysis was performed for predictors of local control (LC) and prognostic factors for overall survival (OS).A total of 21 patients had 24 sites that were treated. The median age was 87 (range 25-103) and median KPS was 70. The most common histology was squamous cell carcinoma (SCC) 19/24 (79 %), basal cell carcinoma (BCC) 3/24 (16 %), and melanoma (4 %). The median maximal diameter was 3.7 cm (range 1-10 cm). The most commonly treated site was lymph nodes in the neck 13/24 (54 %), skin 8/24 (33 %), 4/24 (16 %) other HN mucosal primary sites. Of the 24 lesions, 17 (71 %) were de novo, without prior treatment and 7/24 (29 %) were recurrent. The most commonly used dose/fraction (fx) was 40 Gy/5 (fx) (range 35/5fx-48/6fx). Of the 24 lesions, 6 (25 %) had complete response, 16/24 (67 %) had partial response, and 2/24 (8 %) had no response. Control was defined as no further progression after treatment. For the entire cohort, LC at 3, 6, and 9 months were 66, 50, and 33 %, respectively. In the de novo group, 2/16 (12.5 %) had local failures with the LC rate of 94, 94, and 87 % at 3 months, 6 months, and 1 year, respectively. In the recurrent group, 4/8 (50 %) had failure with LC rates of 87. 5, 62.5, and 50 % at 3 months, 6 months, and 1 year, respectively. Of the 21 patients, 10 died during follow up, with the OS rate at 3 months, 6 months, and 1 year of 90, 70, and 60 %, respectively. Being defined "de novo" showed a trend toward statistical significance p = 0.046 for local failure. Overall survival did not show significant difference between de novo and recurrent with a p value of 0.267. No significant prognostic variables for OS were found. Pre-treatment QOL scores for the entire cohort were 53/130 versus 38/130 (lower scores indicating better QOL) scores with a trend toward statistical significance p = 0.05.SBRT is efficacious with improved quality of life within this elderly frail population in the treatment of de novo and recurrent tumors of the head and neck with promising quality of life scores.

The purpose of this study was to evaluate bilateral kidney and target translational/rotational intrafraction motion during stereotactic body radiation therapy treatment delivery of primary renal cell carcinoma and oligometastatic adrenal lesions for patients immobilized in the Elekta BodyFIX system. Bilateral kidney motion was assessed at midplane for 30 patients immobilized in a full‐body dual‐vacuum‐cushion system with two patients immobilized via abdominal compression. Intrafraction motion was assessed for 15 patients using kilovoltage cone‐beam computed tomography (kV‐CBCT) datasets (n=151) correlated to the planning CT. Patient positioning was corrected for translational and rotational misalignments using a robotic couch in six degrees of freedom if setup errors exceeded 1 mm and 1°. Absolute bilateral kidney motion between inhale and exhale 4D CT imaging phases for left–right (LR), superior–inferior (SI), and anterior–posterior (AP) directions was 1.51±1.00mm,8.10±4.33mm, and 3.08±2.11mm, respectively. Residual setup error determined across CBCT type (pretreatment, intrafraction, and post‐treatment) for x (LR), y (SI), and z (AP) translations was 0.63±0.74mm,1.08±1.38mm, and 0.70±1.00mm; while for x (pitch), y (roll), and z (yaw) rotations was 0.24±0.39°,0.19±0.34°, and 0.26±0.43°, respectively. Targets were localized to within 2.1 mm and 0.8° 95% of the time. The frequency of misalignments in the y direction was significant (p

To develop a volumetric modulated arc therapy (VMAT) treatment planning solution in the treatment of primary renal cell carcinoma and oligometastatic adrenal lesions with stereotactic body radiation therapy. Single-arc VMAT plans (n = 5) were compared with clinically delivered step-and-shoot intensity-modulated radiotherapy (IMRT) with planning target volume coverage normalized between techniques. Target volume conformity, organ-at-risk (OAR) dose, treatment time, and monitor units were compared. A VMAT planning solution, created from a combination of arc settings and optimization constraints, auto-generated treatment plans in a single optimization. The treatment planning solution was evaluated on 15 consecutive patients receiving kidney and adrenal stereotactic body radiation therapy. Treatment time was reduced from 13.0 ± 2.6 to 4.0 ± 0.9 minutes for IMRT and VMAT, respectively. The VMAT planning solution generated treatment plans with increased target homogeneity, improved 95% conformity index, and a reduced maximum point dose to nearby OARs but with increased intermediate dose to distant OARs. The conformity of the 95% isodose improved from 1.32 ± 0.39 to 1.12 ± 0.05 for IMRT and VMAT treatment plans, respectively. Evaluation of the planning solution showed clinically acceptable dose distributions for 13 of 15 cases with tight conformity of the prescription isodose to the planning target volume of 1.07 ± 0.04, delivering minimal dose to OARs. The introduction of a stereotactic body radiation therapy VMAT treatment planning solution improves the efficiency of planning and delivery time, producing treatment plans of comparable or superior quality to IMRT in the case of primary renal cell carcinoma and oligometastatic adrenal lesions.

Aims To report the outcomes of a cohort of patients with renal cell carcinoma (RCC) treated using stereotactic ablative body radiotherapy (SABR). Materials and methods Patients treated with SABR for primary RCC from 1 January 2012 to 1 April 2015 were retrospectively reviewed. Patients were non-surgical candidates treated with doses ranging from 30 to 40 Gy in five fractions. The tumour sizes and serum creatinine were compared between the pre-treatment assessment and subsequent follow-up assessments. The worst acute and late grade ≥2 toxicity rates were recorded. Results In total, 16 patients were included in this study. The median follow-up was 19 months (range 7–30). Eleven patients had stable disease, four had partial responses and none had progressive disease, indicating a local control rate of 100%. One patient had grade 2 acute nausea and two patients had grade 4 renal toxicities (two patients with pre-existing stage 4–5 chronic kidney disease required dialysis following SABR). Four of four patients with pre-SABR symptoms (pain and/or haematuria) had symptomatic relief after SABR. Conclusion SABR for RCC is safe, the toxicities are minimal, and the local control is excellent at early follow-up. This technique should be further evaluated in prospective clinical trials.

the oral cavity, oropharynx, nasopharynx, hypopharynx, and larynx, often managed with a combination of surgery, chemotherapy, and radiation therapy. Prognostic factors affecting treatment outcomes in the elderly have not been clearly defined in the literature. Patient-specific factors may be important when considering treatment options for this population in order to maximize patient survival and post-treatment quality of life (QOL). This study aims to explore and clarify the role of key prognostic factors on outcomes in HNC patients over the age of 80 years treated with radiation therapy at the Odette Cancer Centre (OCC). Methods and Materials: From a database of 933 HNC patients treated at OCC between Jan 2007 and December 2012, a sample of 40 eligible patients will be randomly selected. Prognostic factors identified from the literature will be extracted from relevant patient records and recorded in a database in three key categories: disease-related, treatment-related and patient-specific. Patient outcome datadoverall survival and rates of recurrence, treatment completion, and radiation toxicitydwill also be retrieved and recorded. Univariate analysis will be employed to determine which of the patient, disease, and treatment factors significantly predict for outcomes in this population. Results: 92.5% of patients successfully completed their treatment as prescribed. Though palliative patients (mean age 89, median 91) were likely to be older than radical patients (mean age 84.7, median 84), no connection was found between age and outcome measures. Dose, fractionation, and stage were not found to significantly impact outcomes in this sample. Mortality status was unavailable for 25% of patients. Further data collection is ongoing to confirm these and other findings. Conclusions: Preliminary results suggest that choice of treatment regime may be tailored to patient convenience without compromising outcome, and that many older patients are able to successfully complete even aggressive radical therapy. The results of this study and the database from which the sample was drawn may be useful in further studies to inform practices in the HN site group at OCC. Prognostic data may also be utilized to create a medical nomogram, in the form of a visual tool useful in facilitating patient-specific education during the informed consent procedure.