distinguishing grade 1 meningioma from higher grade meningiomas without biopsy
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Volume 87 � Number 2S � Supplement 2013 Digital Poster Discussion Abstracts S157
looked for ongoing trials at clinicaltrials.gov and controlled-trials.com.
Referenced studies cited in published guidelines for prostate cancer as
well as in reviews and other relevant articles identified in the search were
also assessed for eligibility. The systematic review was conducted
following a pre-established protocol. RCTs comparing intermittent
(IAD) versus continuous (CAD) androgen deprivation therapy (any
regimen) for patients with prostate cancer (any stage) were considered
eligible. Primary outcomes were overall survival and quality of life.
Secondary outcomes were cancer-specific survival, progression-free
survival (biochemical and/or clinical), time to castration resistance,
skeletal-related events and side effects. Duration of off-treatment inter-
vals and testosterone levels were also considered for the IAD group. Two
reviewers performed study selection, data abstraction and risk of bias
assessment, independently. Hazard ratios using random effect models
were conducted with generalized inverse variance method. Heterogeneity
was assessed using I2 statistic.
Results: Among 8280 references, 14 studies were eligible. All studies
presented an unclear or high risk of bias for the two primary outcomes.
There was no significant difference between IAD and CAD in terms of
overall survival (HR 1.02, 95% CI: 0.93-1.13; 5 studies, 4239 patients),
cancer-specific survival (HR 1.00, 95% CI: 0.76-1.32; 3 studies, 1318
patients), and progression-free survival (HR 0.95, 95% CI: 0.78-1.14; 4
studies, 2704 patients). In 10 trials providing data on quality of life, 8 used
different version of the EORTC QLQ-C30 questionnaire and 2 used other
questionnaires. These studies observed variable results. No difference
between the two interventions was observed for hot flashes, gynecomastia,
depression, erectile dysfunction, decreased libido, and cardiovascular
death.
Conclusions: In our systematic review, we did not observe a difference in
overall survival between IAD and CAD. Although quality of life outcomes
were evaluated in most studies, firm conclusions cannot be made due to
differences in questionnaires used and inconsistent results.
Author Disclosure: S. Magnan: None. L. Pilote: None. L. Bernier: None. V.
Fradet: None. E. Vigneault: None. A.F. Turgeon: None.
1024Duration of Androgen Deprivation Therapy Influences Outcomes forPatients Receiving Radiation Therapy Following RadicalProstatectomyW.C. Jackson,1 S.B. Johnson,1 C. Foster,1 D. Li,1 H.M. Sandler,2
G.S. Palapattu,1 D.A. Hamstra,1 and F.Y. Feng1; 1University of Michigan,
Ann Arbor, MI, 2Cedars-Sinai, Los Angeles, CA
Purpose/Objective(s): Concurrent/adjuvant androgen deprivation therapy
(ADT) is known to improve survival for patients receiving radiation
therapy (RT) as a primary treatment for localized prostate cancer. The
optimal duration of ADT with RT varies by prostate cancer risk stratifi-
cation. Short-term (4-6 months) concurrent ADT is considered for those
with intermediate-risk disease, and long-term (2-3 years) ADT is recom-
mended for those with high-risk disease. Less in known regarding the
optimal duration of ADT in patients who receive either adjuvant or salvage
RT (ART or SRT) for a rising prostate-specific antigen (PSA) following
radical prostatectomy (RP). We sought to assess if the duration of ADT use
influences clinical outcomes for patients receiving RT post-RP.
Materials/Methods: Six hundred eighty patients who received ART or
SRT at a single institution post-RP were retrospectively reviewed in an IRB
approved analysis. We assessed the impact of ADT duration on
biochemical failure (BF), distant metastasis (DM), prostate cancer-specific
mortality (PCSM), and overall mortality (OM) using Kaplan-Meier and
Cox Proportional Hazards models.
Results: One hundred forty-four patients (17%) received concurrent/
adjuvant ADT with post-RP RT. One hundred thirteen patients received
SRT and 31 received ART. No difference existed between the mean
duration of ADT in SRT and ART (p Z 0.6). Median follow-up post-RT
was 57.4 months. Median ADT duration was 12 months (interquartile
range [IQR] 6.0-23.7). Patients receiving ADT were dichotomized using
median ADT duration. Patients who received <12 months of ADTwere at
an increased risk for BF (hazard ratio [HR]: 2.3, p Z 0.003) and DM (HR:
2.5, p Z 0.03) as compared to patients receiving >12 months of ADT. 5-
year rates of DM were 6% and 23% for those receiving >12 months, and
<12 months of ADT, respectively. On multivariate analysis, when
controlling for pre-RT PSA, Gleason score, seminal vesicle invasion,
extracapsular extension, presence of positive surgical margins, and the use
of ART vs SRT, each month of ADT was associated with a 1.1-fold
decrease in risk of BF (p Z 0.01), DM (p Z 0.01), PCSM (p Z 0.04), and
OM (p Z 0.04). Thus, patients who received 6 months of ADT had a 1.8
fold decrease in risk of BF, DM, PCSM, and OM, whereas patients who
received 24 months of ADT had a 9.8-fold decrease in risk of BF, DM,
PCSM, and OM.
Conclusions: For patients receiving concurrent/adjuvant ADT with post-
RP RT, the duration of ADT impacts clinical outcomes. Each month of
ADT was associated with a statistically significant decrease in BF, DM,
PCSM, and OM. Our findings suggest that for patients receiving concur-
rent/adjuvant ADT with post-RP RT, an extended course of ADT may be
preferable. This is consistent with the hypothesis that patients experience
BF after post-RP RT because of subclinical metastatic relapse rather than
failure of RT to eradicate pelvic disease.
Author Disclosure: W.C. Jackson: None. S.B. Johnson: None. C. Foster:
None. D. Li: None. H.M. Sandler: None. G.S. Palapattu: None. D.A.
Hamstra: None. F.Y. Feng: None.
1025Distinguishing Grade 1 Meningioma From Higher GradeMeningiomas Without BiopsyM. Pavelic,1 C. Specht,2 D. Timik,2 J. Liao,1 S. Kanekar,2 S. Sogge,1
M. Glantz,1 J. Sheehan,3 and J. Varlotto1; 1Penn State Hershey Cancer
Institute, Hershey, PA, 2Penn State Hershey Medical Center, Hershey, PA,3Penn State Hershey Neuroscience Institute, Hershey, PA
Purpose/Objective(s): Many meningiomas are identified radiographi-
cally, assumed to be Grade I tumors, and are followed. The purpose of our
investigation is to find clinical or radiographic predictors of WHO Grade
II/III tumors(Gr II/III) in order to distinguish them from WHO Grade I.
Materials/Methods: Patients with a pathologic diagnosis of meningioma
from 2002-2009 were included if they had pre-operative MRI studies and
pathology for review. Thirty of the 82 tumors were classified as Gr II/III.
All pathology was reviewed and classified by WHO 2007. All Brain MRI
imaging was reviewed and tumors were assessed for brain invasion,
volume, maximum diameter, herniation, apparent diffusion coefficient,
necrosis, vascularity (quantified by degree of enhancement, 1-4), associ-
ated bleed, and cystic change. Clinical factors analyzed included symp-
toms, age, sex, medications, smoking status, body mass index (BMI),
Charlson comorbidity index, and diabetes. Pathology and Radiology
reviews were blinded from each other and from clinical course. Univariate
and Multivariate logistic regressions were used to find predictive factors
for Gr II/III.
Results: Univariate analysis demonstrated that the following factors
were associated with Gr II/III: Brain Invasion, degree of vascularity, and
volume of lesion (at p value < 0.05). Our multivariate logistic model
contains predictors of tumor vascularity (p Z 0.038, Odds Ratio Z1.83 for unit increase of vascularity), and brain invasion (p Z 0.065,
Odds Ratio Z 2.48). 64% of tumor associated with grade 4 vascularity
(n Z 17) had a Gr II/III compared to 27.7% of tumors with less
vascularity. Brain invasion was seen in 32 patients, 50.0% of which had
Gr II/III as compared to 28.3% without brain invasion. A total of 88.8%
tumors with both grade 4 vascularity and brain invasion (N Z 9) were
Gr II/II.
Conclusions: Tumors without high-grade vascularity and brain invasion
are more likely to be Grade I meningiomas. Clinical and radiographic
surveillance rather than immediate surgery may be considered for these
patients.
International Journal of Radiation Oncology � Biology � PhysicsS158
Author Disclosure: M. Pavelic: None. C. Specht: None. D. Timik: None. J.
Liao: None. S. Kanekar: None. S. Sogge: None. M. Glantz: None. J.
Sheehan: None. J. Varlotto: None.
1026Benefit of Adjuvant Radiation Therapy (RT) in Management ofRecurrent Atypical Meningioma (AM)S.E. Braunstein, M. Dayal, C. Tinkle, J. Chang, G. Kaur, A. Perez-
Andujar, C. Chuang, L. Ma, A. Parsa, and I.J. Barani; University of
California San Francisco, San Francisco, CA
Purpose/Objective(s): AM (WHO grade II) comprise a broad class of
brain tumors stratified between benign and anaplastic meningiomas,
characterized by heterogeneous pathologic characteristics. Several series
have demonstrated high recurrence risk of AM, with 10 yr recurrence rates
(RR) approaching 50% after gross total resection, associated with modest
overall survival. Adjuvant RT is associated with lower RR, although the
role of RT remains unclear. Given the high rates of recurrence in the setting
of varied multimodal approaches to initial AM management, we investi-
gated the role of RT in treating recurrent AM.
Materials/Methods: We performed a retrospective review of 94 patients
with AM, seen at UCSF from 1995 through 2012, for which we identified
35 patients with recurrence by imaging and treatment records. Patient and
treatment characteristics at initial diagnosis were noted, including age,
tumor location, extent of surgery, adjuvant RT, and symptomatic response.
Successive features were analyzed after recurrence along with subsequent
progression free survival (PFS).
Results: For the cohort of 35 patients who recurred, mean age at diag-
nosis was 59 yrs (range, 18 - 79 yrs). Gender distribution was 17 male
and 18 female patients. Incidence by anatomic site was: 12 convexity, 10
parasagittal, 6 sphenoid, 3 posterior fossa, 3 midline anterior fossa, and 2
other. Seventeen patients received gross total resection (GTR), and 18
had subtotal resection (STR) at initial surgery. Six patients received
adjuvant RT (2 post-GTR; 4 post-STR). Mean time to initial recurrence
was 29 mos (range, 1 mo to 96 mos). Forty percent (14 of 35) of patients
received interval resection (2 GTR; 12 STR), with evidence of
progression to WHO Grade III in 1 patient. Twenty-seven patients
received adjuvant RT: 17 with EBRT to median dose of 59.4 Gy in 33 fx;
9 with SRS to median dose of 15 Gy in 1 fx; and one implant of 3.8 mCi
I-125. For patients receiving RT, subsequent actuarial PFS was 58.5% at
2 yrs, and 29.2% at 5 yrs over a median follow-up period of 19 mos from
first recurrence. Overall survival was 74.3% at 5 yrs from initial diag-
nosis (87.5% with RT vs 37.5% without RT at recurrence, p Z 0.007).
Further analysis showed no PFS association with age, sex, location, or
RT modality at recurrence.
Conclusions:With RTOG 0539 pending, these data confirm the high RR of
AM and support adjuvant RT in their subsequent management. Short
interval to recurrence, with modest overall survival, is consistent with prior
studies. Moreover, single fraction SRS may yield local control comparable
to EBRT in select patients. Current efforts are directed towards further
resolving dose-volume relationships and RT modality for effective
management.
Author Disclosure: S.E. Braunstein: None. M. Dayal: None. C. Tinkle:
None. J. Chang: None. G. Kaur: None. A. Perez-Andujar: None. C.
Chuang: None. L. Ma: None. A. Parsa: None. I.J. Barani: None.
1027Patterns of Failure for Grade 2/3 Meningioma Treated WithReduced Margin Intensity Modulated Radiation TherapyR.H. Press,1 R.S. Prabhu,2 C.L. Appin,2 D.J. Brat,2 H.G. Shu,2
C. Hadjipanayis,2 J.J. Olson,2 N.M. Oyesiku,2 W.J. Curran,2
and I. Crocker2; 1Emory University School of Medicine, Atlanta, GA,2Emory University Winship Cancer Institute, Atlanta, GA
Purpose/Objective(s): The standard of care for grade II and III menin-
giomas is surgical resection and adjuvant radiation therapy (RT). Typical
clinical target volume (CTV) expansions for microscopic disease extension
are 1 - 2 cm. Additional planning target volume (PTV) expansions of 0.5
cm to 1 cm bring the standard total expansion to 1.5 to 3 cm. Previous
studies have generally used a variety of RT techniques with standard CTV
margins. The purpose of this study was to evaluate intracranial control and
patterns of local recurrence (LR) for grade II and III meningiomas treated
with intensity-modulated radiation therapy (IMRT) with predominantly
limited total margins of �10 mm.
Materials/Methods: The records of patients with neuropathologist diag-
nosis of grade II or III meningioma who underwent IMRT between 2003
and 2012 were reviewed. Exclusion criteria included follow-up period <4
months. Information recorded included pt and tumor characteristics,
surgical and radiation details, and tumor control. Actuarial rates were
determined by the Kaplan-Meier method from the end of RT. LR was
defined as in-field if �90% of the recurrence was within the prescription
isodose, out-of-field if �90% outside of prescription isodose, and both if
neither.
Results: Between 2002 and 2012, 59 consecutive patients underwent
IMRT for grade II/III meningioma with a median imaging follow-up
period of 26 months (range, 4 - 107 months) for alive patients. Fifty-six
patients (95%) and 3 patients (5%) had grade II and III meningiomas,
respectively. IMRT was adjuvant after surgery for 51 patients (86%) and
was definitive therapy for 8 patients (14%). The median dose for frac-
tionated IMRT was 59.4 Gy (range, 49.2 - 61.2 Gy). The median CTV,
PTV, and total margins were 5 mm, 3 mm, and 8 mm, respectively, with
unknown margins in 3 patients. Of patients with known margins (n Z 56),
81% had total margin �10 mm. LR occurred in 13 patients (22%), with 2-
year and 5-year actuarial LR of 5% and 45%, respectively. Eleven of 13
patients (85%) had a known pattern of LR. Seven patients, 2 patients, and 2
patients had in-field only, out-of-field only, and both patterns of LR. Of the
2 patients with out-of-field only LR, total margins were 25 mm and 3 mm,
respectively. Two-year and 5-year overall survival (OS) was 85% and 69%,
respectively.
Conclusions: The LR rate and OS in this series using IMRT only with total
margins (CTV + PTV) predominantly �10 mm is similar to other pub-
lished studies using standard margins. Most recurrences occur >3 years
after RT. Of the 48 patients who had margins �10 mm, only 1 failed out-
of-field only. RTOG 05-39 recommends CTV margins of 1 - 2 cm
depending on grade and extent of resection. These results support the
efficacy of treating patients with grade II and III meningiomas with
reduced margins without excess risk of out-of-field failure. Reduced
margins may be associated with lower toxicity, but further studies are
needed.
Author Disclosure: R.H. Press: None. R.S. Prabhu: None. C.L. Appin:
None. D.J. Brat: None. H.G. Shu: None. C. Hadjipanayis: None. J.J. Olson:
None. N.M. Oyesiku: None. W.J. Curran: None. I. Crocker: K. Stock;
Velocity Medical Systems. Q. Leadership; Velocity Medical Systems.
1028Mixed Proton and Photon Therapy for Benign Meningiomas: Long-term Results of a Prospective Randomized Dose Escalation StudyH.A. Shih, N.N. Niu, E. Pan, J. Daartz, B.Y. Yeap, J.E. Munzenrider,
and J.S. Loeffler; Massachusetts General Hospital, Boston, MA
Purpose/Objective(s): Optimal dose for management of benign menin-
giomas is unclear. Proton therapy permits for consideration of safer dose
escalation and was delivered at two different doses with the objective to
assess outcomes of progression free survival (PFS), overall survival (OS),
and treatment-related toxicity.
Materials/Methods: Patients with recurrent or subtotally resected benign
meningiomas were enrolled on a prospective trial of mixed proton and
photon therapy with randomization to 55.8 Gy (RBE) versus 63 Gy (RBE).
All patients received 80% of their radiation with proton therapy. Photon
radiation was delivered once weekly.
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