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This analysis was performed to describe the outcome of very elderly (≥ 80 years) patients with small-cell lung cancer (SCLC) as there is no published data regarding these patients.One hundred forty-six very elderly patients with SCLC were identified from the Institutional Lung Cancer Database ranging in age from 80 to 92 years (median, 82 years). Of these, 47 (32%) patients had limited-stage SCLC (L-SCLC), and 99 (68%) had extensive-stage SCLC (E-SCLC). All were Caucasian, and the majority (64%) were female. Sixty-seven (46%) patients had Zubrod performance status (PS) of 0 to 1.Of the 146 patients, 44 (30%) received no therapy, 65 (45%) received chemotherapy alone, 27 (19%) received chemotherapy plus local therapy (thoracic radiotherapy [TRT] or surgery), and 10 (7%) received local therapy alone. The median survival was 5.4 months. On univariable analysis, age (P = .019), stage (L-SCLC vs. E-SCLC; P = .0002), PS (P .0001), and treatment option (P .0001) were associated with survival. On multivariable analysis, stage (P = .011), PS (P = .029), and treatment option (P .0001) maintained significance. For entire cohort, the median survival was 1.3 months without active therapy, 6 months with local therapy alone, 7.2 months with chemotherapy alone, and 14.4 months with chemotherapy plus local therapy (P .0001, univariable and multivariable). Similar survival findings in response to treatment were found when the L-SCLC and E-SCLC cohorts were separately analyzed.The survival of very elderly patients with SCLC was associated with stage (L-SCLC vs. E-SCLC), PS, and treatment option. Very elderly patients with SCLC often have limited functional reserve required to tolerate aggressive multimodality therapy but appeared to benefit from it. Geriatric assessments, careful monitoring, and extra support are warranted in elderly patients. Care should be individualized based on the desires and needs of each patient.

BACKGROUND Radiation is an integral component of the multidisciplinary treatment of patients with intracranial metastasis (ICM) from melanoma. The risk of radiation necrosis (RN) post-treatment can range from 5–25%. We retrospectively evaluated pre- and post-radiation clinical and radiographical characteristics in patients with ICM from melanoma to identify potential risk factors for RN. METHODS After IRB approval, patients with ICM from melanoma who received radiation at our institution between 2013 and 2018 were retrospectively reviewed. We recorded demographics, intracranial metastasis (burden and location), systemic therapy, resection, stereotactic radiosurgery versus whole brain radiation, and outcomes. Brain MRI was evaluated using the Response Assessment in Neuro-Oncology criteria (RANO). RESULTS A total of 27 patients were included in the study. RN was diagnosed in 14 patients (52%) at one month to three years following radiation. Cerebellar location (n=7) was significantly associated with RN (p=0.0058). Metastasis-associated hemorrhage was present in 7 patients, 6 of which developed RN (43% vs 8%, p=0.08). Surgical resection prior to radiation was performed in 9 patients, 7 of which developed RN (50% vs 15%, p=0.1). RN appeared to be less often diagnosed when ICM were treated with higher doses of radiation (24 Gy vs 20 Gy, p=0.07). Systemic treatment was administered prior to radiation in 25 patients and we found no relationship with systemic therapy type and RN. Presumed RN was treated in 12 of 14 patients (86%). Steroids or surgical resection were the primary treatment modalities, with laser ablation used in 1 case. Following treatment, improvement was noted in 3 patients radiographically and in 1 of these clinically. CONCLUSIONS This series of patients with radiotherapy-treated brain metastases from melanoma reveals cerebellar involvement, hemorrhage, and prior surgical resection as potential risk factors for radiation necrosis. Neoadjuvant systemic treatment did not appear to be a risk factor in our review.

Objectif de l’etude Cette etude retrospective nationale a evalue l’apport de la radiotherapie postoperatoire dans les carcinomes thyroidiens differencies de pronostic defavorable. Materiel et methode Les patients etaient eligibles sur ces criteres : carcinomes thyroidiens differencies de stade T3 ou T4, et/ou avec envahissement ganglionnaire avec rupture capsulaire, et/ou en recidive locoregionale, et/ou ne fixant pas l’iode. L’impact de la radiotherapie sur la recidive locoregionale a ete evaluee par un modele de Fine et Gray de maniere a prendre en compte le deces et la recidive metastatique comme evenements competitifs. Des facteurs pronostiques de recidive locoregionale ont ete recherches dans le sous-groupe des patients irradies. Resultats Au total, 254 patients (de 18 centres) ont ete inclus, dont 38 operes non irradies. Le suivi median etait de 78 mois. Les incidences cumulees de recidive locoregionale etaient respectivement a 5 et 10 ans de 18,6 % et 28,1 %. Les probabilites de survie globale a 5 et 10 ans etaient de 78,4 % et 63,0 %. Apres ajustement sur les facteurs de confusion potentiels, la radiotherapie diminuait le risque de recidive locoregionale avec un hazard ratio (HR) de 0,26 et un intervalle de confiance (IC) a 95 % de [0,13 ; 0,54]. A 10 ans, l’incidence cumule de recidive locoregionale etait de 23 % [17 % ; 30 %] pour les patients irradies contre 56 % [32 % ; 74 %] pour les patients non irradies. Apres ajustement sur les facteurs de confusion, la radiotherapie n’apportait pas de benefice de survie globale (HR : 0,82 ; IC95 % : 0,41–1,64). Parmi les patients irradies, la thyroidectomie totale diminuait le risque de recidive locoregionale alors que l’histologie insulaire le majorait. Conclusion La radiotherapie postoperatoire permet d’ameliorer le taux de controle locoregional dans les carcinomes thyroidiens differencies de pronostic defavorable.

Objectifs Les cancers anaplasiques de la thyroide sont des maladies rares et de pronostic tres defavorable, avec une duree mediane de survie de 10 mois. L’objectif de cette etude etait d’evaluer l’impact sur la survie globale de la strategie therapeutique multimodale. Patients et methodes Les dossiers des patients atteints de cancer anaplasique de la thyroide traite a une dose d’au moins 40 Gy dans les centres du groupe du Rare Cancer Network ont ete analyses. Resultats Au total, parmi les 140 cancers anaplasiques de la thyroide, 25 % avaient une double composante differenciee et indifferenciee. Treize patients ont recu une chimiotherapie neoadjuvante (avec differents protocoles), avec 63 % de reponses partielles. Parmi 68 patients ayant ete operes (dont 63 % par thyroidectomie totale, 70 % avec curage ganglionnaire cervical), 18 % ont eu une exerese complete. Quatre-vingt pour cent des patients ont recu une chimioradiotherapie concomitante (y compris par doxorubicine, docetaxel, cisplatine, carboplatine), 80 % des patients ont eu une radiotherapie externe dans de larges volumes, 20 % dans des volumes limites, et une dose mediane de 60 Gy a ete delivree. Les durees medianes de controle locoregional, survie sans metastase et survie globale etaient respectivement de 16, 14 et 17 mois. L’analyse multifactorielle a montre que la chirurgie et une haute dose de radiotherapie etaient des facteurs independants de la survie globale. Les patients ayant recu une radiotherapie conformationnelle avec modulation d’intensite semblent avoir de meilleurs resultats. Conclusion L’etude est en cours, il faut probablement jusqu’a 300 patients pour confirmer l’ordre optimal entre la chirurgie, la chimiotherapie et la radiotherapie.

(NSQ) histology and have expanded to include oral targeted therapies. This study examines oral and infused SATx by line of therapy (LOT) and histology in a more recent population-based cohort. Materials/Methods: Patients aged 66 who had Medicare Parts A/B/D fee-for-service insurance coverage and were diagnosed with stage IIIB/IV NSCLC in 2007-9 were identified in the United States SEER-Medicare data and classified as squamous (SQ), NSQ, or unclassified histology (not otherwise specified [NOS]). We examined patients’ demographic and clinical characteristics, patterns of SATx (chemotherapy, tyrosine kinase inhibitors, and monoclonal antibodies), and the relationship of SATx to histology. Results: Of 7080 eligible patients, 26% had SQ, 51% had NSQ, and 24% had NOS histology; 28% were stage IIIB and 72% stage IV. Overall, 44% of all patients received at least first-line (1L) SATx (NSQ 46%, SQ 41%, NOS 43%; PZ.0013 across all categories and PZ.0006 for NSQ vs SQ). Only 19% of all patients received secondline (2L) SATx (NSQ 21%, SQ 16%, NOS 18%; P

IMRT in H&N cancer has yielded significant dosimetric improvements compared to the conventional 3D conformal radiotherapy. The benefits shown in several studies were delivering higher dose to target volumes while limiting the dose to organs at risk, especially for parotid gland, spinal cord and brainstem. H&N cancer can be treated using the sequential IMRT based on a conventional fractionation approach or the simultaneous integrated boost technique (SIB). The SIB-IMRT approach is used to increase the fraction dose to the boost volume while maintaining the dose to the elective volume at a lower dose level. Several studies with the SIB-IMRT showed that the technique produced better coverage of boost volume and less doses to critical organs and normal tissues in addition to fewer fraction treatment. However, the sequential IMRT may be better than SIB-IMRT for some H&N cases depending on medical and biological parameters. Currently, the fractionation strategy, biologic effectiveness and parameters affecting the clinical outcomes are being investigated in H&N cancer.

In clinical practice, evaluation of clinical efficacy of treatment planning stems from the radiation oncologist's experience in accurately targeting tumors, while keeping minimal toxicity to various organs at risk (OAR) involved. A more objective, quantitative method may be raised by using radiobiological models. The purpose of this work is to evaluate the potential correlation of OAR-related toxicities to its radiobiologically estimated parameters in simultaneously integrated boost (SIB) intensity modulated radiation therapy (IMRT) plans of patients with head and neck tumors at two institutions. Lyman model for normal tissue complication probability (NTCP) and the Poisson model for tumor control probability (TCP) models were used in the Histogram Analysis in Radiation Therapy (HART) analysis. In this study, 33 patients with oropharyngeal primaries in the head and neck region were used to establish the correlation between NTCP values of (a) bilateral parotids with clinically observed rates of xerostomia, (b) esophagus with dysphagia, and (c) larynx with dysphagia. The results of the study indicated a strong correlation between the severity of xerostomia and dysphagia with Lyman NTCP of bilateral parotids and esophagus, respectively, but not with the larynx. In patients without complications, NTCP values of these organs were negligible. Using appropriate radiobiological models, the presence of a moderate to strong correlation between the severities of complications with NTCP of selected OARs suggested that the clinical outcome could be estimated prior to treatment.

Purpose/Objective(s): Radiation therapy (RT) for prevention of heterotopic ossification (HO) around the joints has been used for decades. While there is ample evidence to support its use at the hip, data on non-hip joints such as the elbow are scant, with recent studies raising concern over toxicities. We conducted an IRB-approved single-institution retrospective review of our experience delivering radiation to the elbow to evaluate outcomes and complications related to RT. Materials/Methods: From 2003 to 2012, 31 patients received perioperative RT for HO prophylaxis at the elbow. Patients with postoperative films (n Z 20) were included in our study. Data on patient characteristics, treatment details, and clinical status at each encounter were reviewed. Radiological studies were reviewed using 5 classification schemes. Patients were contacted for interview on current status using the Mayo Elbow Performance Score (MEPS). Results: Median patient age was 42.5 years, median body mass index (BMI) was 29, and 85% were male. Mean follow-up was 9.2 months. All patients received a single fraction of 600-700 cGy, preoperatively within 24 hours (n Z 8), postoperatively within 24 hours (n Z 11), or postoperatively in 3 days (n Z 1). Five patients underwent primary prophylaxis while 15 patients received RT for secondary prophylaxis. Two patients developed new HO and 1 patient had progression of disease at the time of follow-up, but all 3 reported a fair MEPS and denied severe functional limitations. Three patients required surgical re-excision of HO. Conclusions: NSAID treatment, whether newly prescribed or prior use, variations in field size, differences in technique, whether open-field AP/PA or 3D conformal with multi-leaf collimation, did not appear to make a difference in risk of recurrence, mal-union, non-union, or functional outcome. Furthermore, all of the subjects available for phone interview, including those with evidence of severe HO, reported fair or better functionality. Timing of RT seems optimal within 24 hours preoperatively or postoperatively. Patients with high-risk indications should undergo primary prophylaxis against HO. Author Disclosure: S.K. Yoo: None. C. Miyamoto: None.

minimum dose of at least 39.2 GyE was achieved in 95% of the plans. Multicomparative and 2-sample t-tests were used. Results: The median GTV and CTV volumes were 43.9 and 56.9 cc, respectively. With median minimum separation from GTV of 0.15 cm (range, 0.0-1.6 cm), the duodenum was the most difficult organ-at-risk (OAR) for meeting dosimetric constraints, especially in the CTV+7 mm cases. For CTV+5 mm planning, selected IMRT and SBPT dosimetric values are shown in Table; P-values were calculated across all 4 proton groups. The integral dose was significantly better for proton vs. IMRT plans (V5Gy, 1663 vs. 3285 cc, P Z 0.0064), as for multiple other OARs. While most proton plans were acceptable, 4-mm spot plans gave slightly less dose to the OAR structures owing to a smaller spot size, but the binary differences (vs. 6-mm spot) were not statistically significant in most cases. Conclusions: Benchmarked against IMRT planning, pancreatic SBPT offers comparable duodenal sparing with significant improvements in most OAR dosimetric metrics considered, which represents an attractive therapeutic option. Under static proton planning considerations, MFO vs. SFO differences were generally not statistically significant. As expected, smaller spot size trended for better OAR sparing. Further proton plan robustness evaluations are warranted to determine the optimal combination of spot size, optimization technique, and target volume for spot placement in spotscanned SBPT. Author Disclosure: T.T. Sio: None. E.J. Tryggestad: None. J.B. Ashman: None. C.J. Beltran: None. W.S. Harmsen: None. K.A. Hoeft: None. S.K. Wurgler: None. R.C. Miller: None.

Results: A total of 898 patients were included. At 2 years, we had data for over 94% of patients. At the early time point 54% of patients had a change in QOL summary that was a MDD or greater for bowel, 37% for urinary incontinence, 78% for urinary obstruction, and 42% for sexual function. At 2 years, a MDD was noted in 29%, 24%, 36%, and 47% for bowel, urinary incontinence, urinary obstruction, and sexual domains, respectively. For those with less than a MDD at the early time, the proportion with MDD at 2 years was 19%, 15%, 14%, and 31%. On MVA, after controlling for age, baseline QOL, PSA, Gleason score, T-stage, prostate volume, and RT technique, an early MDD was the strongest predictor of MDD at 2 years in all domains: OR Z 2.4 [95% CI Z 1.6-3.5] for bowel, OR Z 4.5 [95% CI Z 2.9-6.9] for urinary incontinence, OR Z 3.7 [95% CI Z 2.2-6.4] for urinary irritation, and OR Z 3.7 [95% CI Z 2.55.5] for sexual function. Conclusions: Early QOL decline was the strongest predictor of QOL impacts at 2 years in all domains across multiple RT treatment types. These data require external validation, but are suggestive that early QOL declines may be a viable surrogate for 2 year QOL in future studies. Author Disclosure: S. Zhao: None. J.R. Evans: None. S. DaignaultNewton: None. M.G. Sanda: None. J. Michalski: None. H.M. Sandler: None. D.A. Kuban: None. J.P. Ciezki: None. I.D. Kaplan: None. A.L. Zietman: None. F.Y. Feng: None. L. Hembroff: None. S. Suy: None. C.A. Mantz: A. Employee; 21st Century Oncology. S. Collins: G. Consultant; Accuray. D.A. Hamstra: None.

Purpose: To combine and integrate quality assurance (QA) of target localization and radiation isocenter End to End (E2E) test of BrainLAB ExacTrac system, a new QA approach was devised using anthropomorphic head and neck phantom. This test insures the target localization as well as radiation isocenter congruence which is one step ahead the current ExacTrac QA procedures. Methods: The head and neck phantom typically used for CyberKnife E2E test was irradiated to the sphere target that was visible in CT-sim images. The CT-sim was performed using 1 mm thickness slice with helical scanning technique. The size of the sphere was 3-cm diameter and contoured as a target volume using iPlan V.4.5.2. A conformal arc plan was generated using MLC-based with 7 fields, and five of them were include couch rotations. The prescription dose was 5 Gy and 95% coverage to the target volume. For the irradiation, two Gafchromic films were perpendicularly inserted into the cube that hold sphere inside. The linac used for the irradiation was TrueBeam STx equipped with HD120 MLC. In order to use ExacTrac, infra-red head–array was used to correlate orthogonal X-ray images. Results: Using orthogonal X-rays of ExacTrac the phantom was positioned. For each field, phantommore » was check again with X-rays and re-positioned if necessary. After each setup using ExacTrac, the target was irradiated. The films were analyzed to determine the deviation of the radiation isocenter in all three dimensions: superior-inferior, left-right and anterior-posterior. The total combining error was found to be 0.76 mm ± 0.05 mm which was within sub-millimeter accuracy. Conclusion: Until now, E2E test for ExacTrac was separately implemented to test image localization and radiation isocenter. This new method can be used for periodic QA procedures.« less

Purpose: To describe the design and dosimetric characterization of a simple and economical small animal irradiator. Methods: A high dose rate 192Ir brachytherapy source from a commercially available afterloader was used with a 1.3 centimeter thick tungsten collimator to provide sharp beam penumbra suitable for hemi-brain irradiation of mice. The unit is equipped with continuous gas anesthesia to allow robust animal immobilization. Dosimetric characterization of the device was performed with Gafchromic film. The penumbra from the small animal irradiator was compared under similar collimating conditions to the penumbra from 6 MV photons, 6 MeV electrons, and 20 MeV electrons from a linear accelerator as well as 300 kVp photons from an orthovoltage unit and Monte Carlo simulated 90 MeV protons. Results: The tungsten collimator provides a sharp penumbra suitable for hemi-brain irradiation, and dose rates on the order of 200 cGy/minute were achieved. The sharpness of the penumbra attainable with this device compares favorably to those measured experimentally for 6 MV photons, and 6 and 20 MeV electron beams from a linear accelerator. Additionally, the penumbra was comparable to those measured for a 300 kVp orthovoltage beam and a Monte Carlo simulated 90 MeV proton beam. Conclusions: The small animal irradiator described here can be built for under $1,000 and used in conjunction with any commercial brachytherapy afterloader to provide a convenient and cost-effective option for small animal irradiation experiments. The unit offers high dose rate delivery and sharp penumbra, which is ideal for hemi-brain irradiation of mice. With slight modifications to the design, irradiation of sites other than the brain could be accomplished easily. Due to its simplicity and low cost, the apparatus described is an attractive alternative for small animal irradiation experiments requiring a sharp penumbra.

Purpose: The purpose of this study was to obtain the characteristics of the sequential (SqB) and simultaneous integrated boost (SIB) IMRT methods in head and neck cancer using HART (Histogram Analysis in Radiation Therapy) program. Methods: Ten SqB and seventeen SIB IMRT cases were studied retrospectively. A cumulative mean dose of 71.3 Gy was prescribed sequentially, and a mean dose of 66.2 Gy for SIB method. Homogeneity (HI), radiation conformality indices (RCI) and quality factor (QF) were calculated from dose‐volume histograms (DVHs). In order to estimate the radiobiological outcomes of NTCP, DVH statistics for the critical and hot spots were utilized with Poisson statistics and JT Lyman models in HART. Results: HI, RCI, and QF were 1.11±0.02, 0.97±0.01, 1.00±0.02 in SIB method; and 1.10±0.01, 0.98±0.01, and 0.93±0.03 in SqB method, respectively. Critical spots for parotids, larynx, and esophagus were 0.75±0.03, 0.06±0.02, and 0.34±0.02 in SqB method, and 0.29±0.07

Purpose: To evaluate and compare normal tissue complication probabilities (NTCP) in SIB (simultaneous integrated boost) and SqIB (sequential IMRT boost) IMRT methods in head and neck cancer using the radiobiological modeling of HART program (Histogram Analysis in Radiation Therapy; J Appl Clin Med Phys 11(1): 3013, 2010). Methods: Of the 40 SIB IMRT cases identified in a 2‐year follow up study, 14 SIB (Rx range: 66–70Gy) cases that developed dysphagia(N=11) or xerostomia(N=10) or both types of complications(N=9) were studied. Similarly 10 SqIB cases (Rx=73.5Gy) was studied previously. The TCP and NTCPs were calculated from the dose‐volume histogram (DVH) statistics using the Poisson Statistics (PS) and JT Lyman models respectively. Values for the volume parameter (n), slope parameter (m), tumor control dose (TCD=63.8Gy) and tolerance dose (TD50,5 = 46 and 47 Gy for bilateral parotids and esophagus, respectively) were selected from Luxton et al. (Phys. Med. Biol. 53, 23–36, 2008). Results: In the SIB method (N=14; Student's t‐test), TCP of tumor was estimated to be 0.78±0.02; while NTCP for parotids and esophagus were 0.16±0.10, and 0.20±0.06 respectively. The corresponding numbers in the SqIB method (N=10) were 0.83±0.02; 0.45±0.14 and 0.17±0.09 respectively. Conclusion: In a 2‐year follow up study with SIB treatments, the estimated values of NTCP of esophagus correlated with the severity of dysphagia. In addition, the hot spots were also reduced and better parotid sparing was found in SIB method than in SqIB method which may partially be related to smaller prescription doses. However JT Lyman model provided better correlation between severity of xerostomia and NTCP of parotids; and PS models for tumor progression free survivability in SqIB treatments. These findings are not in direct comparison due to the differences in tumors and stages. This novel methodology of radiobiological outcome‐related analysis can be utilized to evaluate different treatment plan techniques.

Purpose/Objective(s): To compare the impact of SBRT immobilization strategies (S-frame/Dual vacuum) on setup and reproducibility for upper lung tumors. Materials/Methods: Our institutional prospective SBRT database was searched for patients with upper lung tumors, defined as an internal tumor volume superior to T5 vertebra. Initially the full-length dual vacuum was used for all lung SBRT patients. For upper lung tumors, an extended, thermoplastic S-frame was recently added as an option. At simulation, a free-breathing 4-D computed tomography was performed without respiratory gating or breathing control. For each treatment, patients were first set up to isocenter with in-room lasers and skin tattoos. Subsequent shifts from initial couch position were made using cone-beam CT (CBCT) to correct for tumor position. If shifts greater than 4 mm were required, they were applied and a new CBCT would be obtained. Couch shifts were analyzed as square root of sum of squares in x, y, and z-directions. Kaplan-Meier, Fisher’s exact and equal variance t-tests were used. Results: Median follow-up was 8.7 months (quartiles, 4.4-19.1). Between April 2008 and Jan 2012, 88 patients with 93 upper lung tumors (21 central, 72 peripheral) were identified. Median age was 71.8 years. 64 tumors were non-small cell lung cancer (54 primary, 10 recurrent), 29 metastatic from other sites. Lesion sizes were: 3cm (11%). 17 tumors were immobilized with S-frame; 76 with dual vacuum. Dose schemes were: 48Gy/4 fractions (28%), 50Gy/5 fractions (24%), and 54Gy/3 fractions (46%). A total of 347 fractions (65 S-frame, 282 dual vacuum) were delivered. First couch shifts were statistically better with S-frame than dual vacuum (see Table). The first couch shift by CBCT exceeded the 4-mm tolerance in 33 (51%) fractions in S-frame, vs. 217 (77%) in dual vacuum (Fisher’s p < 0.0001). Correction by 1st couch shifts was usually successful, as 2nd couch shifts were similarly small regardless of immobilizing device; 3rd shifts were rarely needed. For all patients, 2 and 3-year local control rates were 94% and 81%, respectively; median has not been reached yet. There is no difference