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73 Background: At our institution, patients who have completed treatment for a locoregionally confined head and neck cancer are followed in a multidisciplinary head and neck survivorship clinic initiated by the administration of a formal, patient specific survivorship care plan (SCP). We sought to assess the impact of these SCP visits on patient understanding of their disease, its treatment, and potential late effects and follow up plans. Methods: An IRB approved survey was administered by an uninvolved third party, to an unselected sequential series of head and neck cancer survivorship patients at the time of a regularly scheduled follow up visit. The survey focused on the knowledge recalled from the SCP, and whether this changed over time. We analyzed two cohorts of patients, based on whether the SCP had been given to them within the last 18 months or not. Results: Preliminary results from the first 20 patients surveyed are presented. These patients received their SCP 3-27 months before being surveyed. Primary tumor sites included oropharynx (16) and larynx (4) and most patients had been treated with intensity modulated radiation therapy (19) and concurrent cisplatin (11). Conclusions: Although patients’ recall about receiving a formal SCP appeared to diminish over time, the information provided by this SCP plan and subsequent survivorship visits was retained. Whether this reflected the SCP itself, or the reinforcement of continued close follow up survivorship visits cannot be determined, but merits further investigation. [Table: see text]

Stereotactic body radiotherapy (SBRT) has emerged as an important treatment option for spinal metastases from renal cell carcinoma (RCC) as a means to overcome RCC's inherent radioresistance. The authors reviewed the outcomes of SBRT for the treatment of RCC metastases to the spine at their institution, and they identified factors associated with treatment failure.Fifty-seven patients (88 treatment sites) with RCC metastases to the spine received single-fraction SBRT. Pain relief was based on the Brief Pain Inventory and was adjusted for narcotic use according to the Radiation Therapy Oncology Group protocol 0631. Toxicity was scored according to Common Toxicity Criteria for Adverse Events version 4.0. Radiographic failure was defined as infield or adjacent (within 1 vertebral body [VB]) failure on follow-up MRI. Multivariate analyses were performed to correlate outcomes with the following variables: epidural, paraspinal, single-level, or multilevel disease (2-5 sites); neural foramen involvement; and VB fracture prior to SBRT. Kaplan-Meier analysis and Cox proportional hazards modeling were used for statistical analysis.The median follow-up and survival periods were 5.4 months (range 0.3-38 months) and 8.3 months (range 1.5-38 months), respectively. The median time to radiographic failure and unadjusted pain progression were 26.5 and 26.0 months, respectively. The median time to pain relief (from date of simulation) and duration of pain relief (from date of treatment) were 0.9 months (range 0.1-4.4 months) and 5.4 months (range 0.1-37.4 months), respectively. Multivariate analyses demonstrated that multilevel disease (hazard ratio [HR] 3.5, p = 0.02) and neural foramen involvement (HR 3.4, p = 0.02) were correlated with radiographic failure; multilevel disease (HR 2.3, p = 0.056) and VB fracture (HR 2.4, p = 0.046) were correlated with unadjusted pain progression. One patient experienced Grade 3 nausea and vomiting; no other Grade 3 or 4 toxicities were observed. Twelve treatment sites (14%) were complicated by subsequent vertebral fractures.Stereotactic body radiotherapy for RCC metastases to the spine offers fast and durable pain relief with minimal toxicity. Stereotactic body radiotherapy seems optimal for patients who have solitary or few spinal metastases. Patients with neural foramen involvement are at an increased risk for failure.

The salivary gland cancers are uncommon neoplasms of the head and neck, which exhibit considerable pathologic, biological, and clinical diversity. Surgical resection, often with postoperative radiation, is the standard therapeutic approach, and the results after treatment vary widely depending on the tumor histology. Chemotherapy has been of only limited palliative benefit in patients with advanced disease, and there has been little exploration of its use in definitive management. Recent investigation has focused on identification of the characteristic molecular signatures and genomic alterations of the specific histologic subtypes. These efforts have suggested the potential for molecularly targeted therapies, and clinical trials exploring this approach are currently underway.

Purpose Palliative radiotherapy is routinely used to treat painful spinal metastases from renal cell carcinoma (RCC). Conventionally planned external beam radiotherapy (CRT) has been standard, with high-dose stereotactic body radiotherapy (SBRT) becoming increasingly common given the radioresistant nature of RCC. We compared the efficacy and durability of pain relief produced by these 2 modalities. Methods and Materials Patients with painful spinal metastases from RCC treated from 2002-2010 were included. Response was defined similar to the Radiation Therapy Oncology Group 0631 protocol: complete response (CR) being resolution of pain without increased narcotics; partial response (PR) included patients with an incomplete reduction in pain without increased narcotics. Patients who experienced a CR or PR were coded as having pain relief, while those with persistent pain or additional narcotics requirements were coded as failures. Achievement of pain relief was analyzed using competing risk analysis with death as the competing event. Time to pain relief was plotted using cumulative incidence analysis. Results A total of 110 patients (34 CRT; 76 SBRT) were included. Median follow-up was 4.3 months (range, 0.2-38). Median Karnofsky performance score was higher for patients treated with SBRT compared with CRT (80 vs 70; P = .0004). Overall pain response rates were 68% for CRT and 62% for SBRT, with respective CR and PR rates of 12% and 56% for CRT, and 33% and 29% for SBRT ( P = .01). Median time to pain relief was 0.6 weeks for CRT versus 1.2 weeks for SBRT ( P = .29). For patients who achieved pain relief (n = 79), median duration was 1.7 months for CRT versus 4.8 months for SBRT ( P = .095). On univariate analysis no factors were significantly related to pain relief. Conclusions CRT was not statistically different than SBRT for pain relief in symptomatic spine metastases from RCC and should be used as first line treatment. The appropriate use of SBRT in this population merits prospective study.

Definitive chemoradiation therapy has evolved as the preferred organ preservation strategy in the treatment of locally advanced head-and-neck cancer (LA-HNC). Dry mouth and dysphagia are among the most common and most debilitating treatment-related toxicities that frequently necessitate the placement of enteral feeding tubes (FT) in these patients to help them meet their nutritional requirements. The use of either a percutaneous endoscopic gastrostomy tube or a nasogastric tube, the choice of using a prophylactic vs a reactive approach, and the effects of FTs on weight loss, hospitalization, quality of life, and long-term functional outcomes are areas of continued controversy. Considerable variations in practice patterns exist in the United States and abroad. This critical review synthesizes the current data for the use of enteral FTs in this patient population and clarifies the relative advantages of different types of FTs and the timing of their use. Recent developments in the biologic understanding and treatment approaches for LA-HNC appear to be favorably impacting the frequency and severity of treatment-related dysphagia and may reduce the need for enteral tube feeding in the future.

We sought to quantify and identify risk factors associated with margin recurrence (MR) requiring salvage radiotherapy after stereotactic body radiation therapy (SBRT) for spinal metastases.We retrospectively reviewed patients with spinal metastases who were treated with single-fraction SBRT between 2006 and 2009. Gross tumor was contoured, along with either the entire associated vertebral body(ies) or the posterior elements, and included in the planning target volume. No additional margins were used. MR was defined as recurrent tumor within one vertebral level above or below the treated lesion that required salvage radiotherapy. Only patients who presented for 3-month post-SBRT follow-up were included in the analysis. Fine and Gray competing risk regression models were generated to identify variables associated with higher risks of MR. MR was plotted using cumulative incidence analysis.SBRT was delivered to 208 lesions in 149 patients. Median follow-up was 8.6 months, and median survival was 12.8 months. The median prescribed dose was 14 Gy (10-16 Gy). MR occurred in 26 (12.5%) treated lesions, at a median time of 7.7 months after SBRT. Patients with paraspinal disease at the time of SBRT (20.8% vs. 7.6% of patients; p = 0.02), and those treated with16 Gy (16.3% vs. 6.3% of patients, p = 0.14) had higher rates of MR. Both variables were associated with significantly higher risk of MR on multivariate analysis.SBRT for spinal metastases results in a low overall rate of MR. The presence of paraspinal disease at the time of SBRT and a dose of16 Gy were associated with higher risks of MR.

Purpose To assess the imaging and clinical outcomes of patients with single brainstem metastases treated with stereotactic radiosurgery (SRS). Materials and Methods We retrospectively reviewed the data from patients with single brainstem metastases treated with SRS. Locoregional control and survival were calculated using the Kaplan-Meier method. Prognostic factors were assessed using a Cox proportional hazards model. Results Between 1997 and 2007, 43 patients with single brainstem metastases were treated with SRS. The median age at treatment was 59 years, the median Karnofsky performance status was 80, and the median follow-up was 5.3 months. The median dose was 15 Gy (range, 9.6–24), and the median conformality and heterogeneity index was 1.7 and 1.9, respectively. The median survival was 5.8 months from the procedure date. Of the 33 patient with post-treatment imaging available, a complete radiographic response was achieved in 2 (4.7%), a partial response in 8 (18.6%), and stable disease in 23 (53.5%). The 1-year actuarial rate of local control, distant brain control, and overall survival was 85%, 38.3%, and 31.5%, respectively. Of the 43 patients, 8 (19%) died within 2 months of undergoing SRS, and 15 (36%) died within 3 months. On multivariate analysis, greater performance status (hazard ratio [HR], 0.95, p = .004), score index for radiosurgery (HR, 0.7; p = .004), graded prognostic assessment score (HR, 0.48; p = .003), and smaller tumor volume (HR, 1.23, p = .002) were associated with improved survival. No Grade 3 or 4 toxicities were observed. Conclusion The results of our study have shown that SRS is a safe and effective local therapy for patients with brainstem metastases.

Purpose: Our previous study showed that weekly dose monitoring using cone-beam CT (CBCT) images can guide the timing and need for adaptive re-planning during the treatment of head and neck (HN) cancer. Here we aim to confirm the dosimetric improvement of adaptive radiotherapy (ART) using weekly CBCTs. Methods: We randomly selected seven HN patients treated with ART due to noticeable anatomic changes. Twenty weekly images acquired during the second treatment course were included. These CBCTs were aligned with both the initial and re-planning simulation CTs according to the clinical shifts. Daily doses were re-calculated for both the initial and adaptive plans. Contours of the tumor and organs-at-risk (OARs) were manually delineated by a physician on the re-planning CT and then were transferred to the CBCTs for plan evaluation. Contour modifications were made based on the daily anatomic changes observed on CBCTs. All patients were treated with 70Gy to the primary tumor and 56Gy to the elective lymph nodes. Results: Volumetric changes of the tumor (range — 43.9%∼+15.9%) were observed. The average D99 to the primary tumor was (70.1±2.0)Gy (range 62.2∼72.5Gy) for the adaptive plan and (66.0±5.5)Gy (range 50.9∼70.7Gy) for the initial plan(p<

e17091 Background: The RTOG and EORTC have reported benefit from adding chemotherapy to post-operative radiation therapy (PORT) in high-risk patients (pts) with squamous cell head and neck cancer, ...

Background. Adenoid cystic carcinoma of the cervix is a rare and aggressive neoplasm for which there are no standardized treatment protocols. Case. A 38-year-old G3P3 Asian female diagnosed with a stage Ib adenoid cystic carcinoma of the cervix with intermediate risk histologic features received a type III hysterectomy in July 2004. She refused external beam radiotherapy, but agreed to be treated with adjuvant vaginal cuff radiation. She has been closely followed and has no evidence of disease to date. Conclusion. Patients with stage Ib adenoid cystic carcinoma of the cervix, especially those with histologic features associated with a higher risk of recurrence, should receive aggressive local therapy, following the guidelines established for similarly staged patients with squamous cell carcinoma of the cervix.

inferior or superior and (iii) quicker to deliver (even at the conventional dose-rate and including on-board, image-guidance for every fraction). Compared to conventionally fractionated 3D technique, the VMAT hypofractionation was overall about one-third (w34%) resource expensive to deliver, with one combination of planning/delivery system (TPS3/linac2 in high-rate mode) as low as one-quarter (w23%) of overall costs. Detailed results for all combinations (VMAT by three planning systems, image-guided delivery by two linac models including the high-dose rate option) is reported with statistical significance of the overall costs difference. Conclusions: Hypofractionated radiation therapy for early-staged lung cancer, as per RTOG0236, already reported superior clinical outcomes. We now document genuine cost-effectiveness: by using the combination of flexible TPSs and modern linacs, simultaneously lower cost and better results can be achieved, a rare combination in modern medicine. Implications for three cancer sites (lung, breast, prostate) will be discussed. Author Disclosure: D.A. Dimitroyannis: None.

Purpose/Objective(s): To report outcomes of patients with laryngeal or hypopharyngeal carcinoma treated with definitive intensity-modulated radiation therapy (IMRT). Materials/Methods: The clinical records of all patients with laryngeal and hypopharyngeal squamous cell carcinomas treated with definitive IMRT at our institution between January 2004 and December 2011 were retrospectively reviewed. Fifty patients were reviewed. All patients would have required a total laryngectomy. Forty-two (84%) patients received concurrent chemotherapy, 6 (12%) received no chemotherapy, and 2 (4%) received adjuvant chemotherapy. Of patients who received concurrent chemotherapy, the majority of them (24 patients, 48%) received cisplatin alone; 6 patients (12%) received cetuximab alone, 8 (16%) received both cetuximab and cisplatin, and 6 (12%) received other chemotherapy regimens. Kaplan-Meier survival analysis and univariate Log-rank statistics were applied. Results: Median follow-up was 26.0 months (range, 4.0-106.0 months). Median age was 61 years (range, 35-83 years); 39 (78%) were male. There were 35 (70%) laryngeal and 15 hypopharyngeal cancers. Twelve (24%), 29 (58%), and 2 (4%) patients were diagnosed clinical stages III, IVA, and IVB, respectively. All patients were prescribed 7000 cGy in 35 daily fractions; however, 2 patients were unable to complete the full treatment. There were 16 local, 7 regional, and 15 distant failures. For all patients, local control (LC), locoregional control (LRC), and overall survival (OS) at 2 years were 73%, 68%, and 63%, respectively. The 2 year LC, LRC and OS for laryngeal cancer were 77%, 75%, and 70%, respectively. For hypopharyngeal cancer, LC, LRC, and OS at 2 years were 54%, 45%, and 47%, respectively. LC and LRC were not significantly different between sites, but there was a trend toward improved OS in patients with laryngeal cancer, (P Z 0.06). Eleven patients underwent salvage laryngectomy (9 laryngeal and 2 hypopharyngeal). Altogether, 34 (68%) patients had a feeding tube placed; 6 (12.5%) before, 25 (50%) during, and 3 (6%) after radiation therapy. At the time of last follow up, only 14 patients (28%) remained feeding tube dependent. Outcomes looking at tumor volume, CTV expansion, and other dosimetric properties will be reported later. Conclusions: The use of IMRT achieved encouraging local and regional tumor control in patients with hypopharyngeal and laryngeal cancer. There is a trend toward worse overall survival in patients with hypopharyngeal compared to laryngeal carcinoma. Feeding tube placement and dependency were common treatment related toxicities but were preferred to the loss of a lung powered voice. Author Disclosure: C. Kreofsky: None. Y.I. Garces: None. D.L. Price: None. K.A. Price: None. R.L. Foote: None.

Purpose: For patients with head and neck (HN) cancer, mid-course adaptive radiation therapy (ART) is a common practice in our institution to accommodate anatomic changes. The aim of the study is to evaluate whether dose re-calculation on weekly verification images can provide quantitative assessment for timely adaptive re-planning with daily image-guided intensity modulated radiotherapy (IMRT). Methods: We retrospectively selected sixty daily verification images acquired on CT-on-rail/CBCT from ten HN patients. These image sets were typically a week apart. Among these patients, six patients received a mid-course ART. Contours of the tumors and organ-at-risks (OARs) were manually delineated by a physician on each verification CT. After placing the treatment iso-center on the verification CTs according to the recorded clinical shifts, daily dose was re-calculated with the same beam configuration as the original plan. For the purpose of this study, electron densities for both verification CTs and planning CTs were set to 1.0 g/cm3. Results: Two patients had D99 of the CTV 45 Gy, two out ten patients required ART at week 2 and two patients required ART at week 3, respectively. Conclusion: Weekly dose monitoring with re-calculation on verification images can provide quantitative dose guidance for timely adaptive re-planning. Future work will include accumulative dose analysis for the decision of adaptive re-planning. The study is supported in part by Siemens Medical Solutions.« less

Purpose: Radiation doses delivered to patients with head and neck cancer (HN) may deviate from the planned doses because of variations in patient setup and anatomy. This study was to evaluate whether off-line Adaptive Radiotherapy (ART) is sufficient. Methods: Ten HN patients, who received IMRT under daily imaging guidance using CT-on-rail/KV-CBCT, were randomly selected for this study. For each patient, the daily treatment setup was corrected with translational only directions. Sixty weekly verification CTs were retrospectively analyzed. On these weekly verification CTs, the tumor volumes and OAR contours were manually delineated by a physician. With the treatment iso-center placed on the verification CTs, according to the recorded clinical shifts, the treatment beams from the original IMRT plans were then applied to these CTs to calculate the delivered doses. The electron density of the planning CTs and weekly CTs were overridden to 1 g/cm3. Results: Among 60 fractions, D99 of the CTVs in 4 fractions decreased more than 5% of the planned doses. The maximum dose of the spinal cord exceeded 10% of the planned values in 2 fractions. A close examination indicated that the dose discrepancy in these 6 fractions was due to patient rotations, especially shoulder rotations. After registeringmore » these 6 CTs with the planning CT allowing six degree of freedoms, the maximum rotations around 3 axes were > 1.5° for these fractions. With rotation setup errors removed, 4 out of 10 patients still required off-line ART to accommodate anatomical changes. Conclusion: A significant shoulder rotations were observed in 10% fractions, requiring patient re-setup. Off-line ART alone is not sufficient to correct for random variations of patient position, although ART is effective to adapt to patients' gradual anatomic changes. Re-setup or on-line ART may be considered for patients with large deviations detected early by daily IGRT images. The study is supported in part by Siemens Medical Solutions.« less

6039 Background: Studies have demonstrated better prognosis for patients (pts) with HPV-initiated OPC when compared to OPC caused by smoking. A small subset of pts however experience disease recurr...

e20558 Background: We applied a novel approach of analyzing and comparing the length and readability of transcribed Informed Consent Conversations (ICCs) with Informed Consent Documents (ICD) for p...

6084 Background: Radiation therapy monotherapy (RT) is standard for patients (pts) with T2N0 squamous cell cancer (SCC) of the glottis. The presence of impaired vocal cord mobility (T2b) is known t...

586 Background: Definitive resection of the primary is frequently part of the management of patients (pts) with stage IV rectal cancer with good performance status and low volume of systemic metastases. It is unclear whether delaying systemic therapy for up front surgical management of the primary compromises overall survival (OS). Methods: Pts with metastatic rectal adenocarcinoma who received definitive surgical resection between 1998-2011 were identified in an IRB approved registry. The sequencing of CT and surgery, and the use of perioperative radiation therapy (RT), was at the discretion of treating physicians. Preoperative chemotherapy (Pre-CT) regimens included 5-fluorouracil (5-FU) +/- leukovorin (LV), capecitabine, 5-FU/LV/oxaliplatin +/- avastin, or 5-FU/LV/irinocetan. RT dose was typically 50.4 Gy. OS was measured from the date of diagnosis. Baseline variables were compared using the Chi-square and unpaired t-tests. OS was calculated using the Kaplan Meier method. Univariate (UVA) and multivariate analysis (MVA) were performed using Cox proportional hazards regression to identify variables associated with OS. Results: In this study of 115 pts, 75 (65%) were treated with pre-CT, while 40 (35%) were treated with up front surgery. Of the pts who received surgery up front, 3 (8%) received RT and of the pts who received pre-CT, 62 (83%) received RT. The cohort was predominantly male (70%) with a median age of 57, median KPS of 80, and median follow-up of 24.1 months. 94% of pts had T3/T4 tumors, 80% had N+ disease, and 33% had poorly differentiated tumors. Liver directed therapy (LDT) was performed in 61% of pts. There was no significant difference in OS (32.3 vs. 32 months; p = 0.24) between pts treated with pre-CT and those who received surgery up front, respectively. UVA demonstrated that pre-CT was not associated with OS (HR 1.26; p = 0.544). MVA demonstrated that pts with poorly differentiated tumors (HR 2.04; p = 0.007) and those that did not undergo LDT (HR 2.45; p = 0.001) had inferior survival. Conclusions: Delaying systemic chemotherapy in order to achieve local control with surgical resection up front does not appear to impact OS in pts with stage IV rectal cancer.

Materials/Methods: From August 2001 through May 2012, 183 patients with cancer of the oral cavity were identified. Following exclusion of patients with prior head and neck cancer, non-squamous histology, no surgery, N2c or greater or M1 staging, or PORT plans unavailable or bilateral necks treated, 57 patients remained for analysis. Patient demographics, tumor, treatment, and outcome information were abstracted from the charts. Regional recurrence was estimated via Kaplan-Meier method and groups were compared via log-rank test. Results: Median follow-up from diagnosis was 21 months range. Primary sites included alveolar ridge (17.5%), buccal (8.8%), floor of mouth (21.1%), hard palate (5.3%), retromolar trigone (5.3%), and oral tongue (42.1%). Primary site was staged T1-2 in 59.6% and T3-4 in 40.4%. Of the cohort, 12% did not undergo neck dissection, while 18% underwent bilateral and 70% ipsilateral neck dissection. Concurrent chemotherapy was used in 26.3% of patients. Of the cohort, 34 (59.6%) patients were found to be clinically or pathologically node negative, out of which 22 (38.5%) were treated with PORT only to the primary site and 12 (21.1%) had primary site and ipsilateral neck PORT; actuarial regional control (RC) at 2 years was 78.6% and 80%, respectively. Of the 4 total regional failures in the PORT-primary only group, 1 patient had a regional only relapse, the remainder failed both locally and regionally. Of the 2 total regional failures in the PORT-primary/ipsilateral neck, both were in the treated neck, and one was both local and regional. Of the node positive patients, all 23 were treated with primary and ipsilateral PORT with 2 year RC rate of 94.7%. The one patient with regional failure relapsed in the treated neck. Conclusions: In selected patients with lateralized oral cavity squamous cell carcinoma it may be reasonable to exclude the N0 bilateral neck, or in ipsilateral node positive neck the contralateral neck, from the post-operative radiation therapy volumes. Author Disclosure: J.A. Contreras: None. N.G. Rao: None. A.M. Trotti: None. J.J. Caudell: None.