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PurposeSeveral accelerated partial breast radiation (APBR) techniques have been investigated in patients with early-stage breast cancer (BC); however, the optimal treatment delivery techniques remain unclear. We evaluated the feasibility and toxicity of APBR delivered using intensity-modulated radiation therapy (IMRT) in elderly patients with stage I BC, using a novel fractionation schedule.Materials and MethodsForty-two patients aged ≥65 years, with stage I BC who underwent breast conserving surgery were enrolled in a phase I/II study evaluating APBR using IMRT. Forty eligible patients received 40 Gy in 4 Gy daily fractions. Patients were assessed for treatment related toxicities, and cosmesis, before APBR, during, and after completion of the treatment.ResultsThe median age was 73 years, median tumor size 0.8 cm and the median follow-up was 54 months. The 5-year locoregional control was 97.5% and overall survival 90%. Erythema and skin pigmentation was the most common acute adverse event, reported by 27 patients (69%). Twenty-six patients (65%) reported mild pain, rated 1-4/10. This improved at last follow-up to only 2 (15%). Overall the patient and physician reported worst late toxicities were lower than the baseline and at last follow-up, patients and physicians rated cosmesis as excellent/good in 93% and 86 %, respectively.ConclusionIn this prospective trial, we observed an excellent rate of tumor control with daily APBR. The acceptable toxicity profile and cosmetic results of this study support the use of IMRT planned APBR with daily schedule in elderly patients with early stage BC.

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Accurate localization of the lumpectomy cavity during accelerated partial breast radiation (APBR) is essential for daily setup to ensure the prescribed dose encompasses the target and avoids unnecessary irradiation to surrounding normal tissues. Three-dimensional ultrasound (3D-US) allows direct visualization of the lumpectomy cavity without additional radiation exposure. The purpose of this study was to evaluate the feasibility of 3D-US in daily target localization for APBR. Materials and methods: Forty-seven patients with stage I breast cancer who underwent breast conserving surgery were treated with a 2-week course of APBR. Patients with visible lumpectomy cavities on high quality 3D-US images were included in this analysis. Prior to each treatment, X-ray and 3D-US images were acquired and compared to images from simulation to confirm accurate position and determine shifts. Volume change of the lumpectomy cavity was determined daily with 3D-US. Results: A total of 118 images of each modality from 12 eligible patients were analyzed. The average change in cavity volume was 7.8% (range,-24.1% to 14.4%) on 3D-US from simulation to the end-of-treatment. Based on 3D-US, significantly larger shifts were necessary compared to portal films in all three dimensions: anterior/posterior (p = 7E-11), left/right (p = 0.002), and superior/ inferior (p = 0.004). Conclusion: Given that the lumpectomy cavity is not directly visible via X-ray images, accurate positioning may not be fully achieved by X-ray images. Therefore, when the lumpectomy cavity is visible on US, 3D-US can be considered as an alternative to X-ray imaging during daily positioning for selected patients treated with APBR, thus avoiding additional exposure to ionizing radiation.

e20509 Background: Pathways associated with proinflammatory molecules are upregulated in oral mucositis. Lalla (Support Care Cancer 18:95, 2010) found an association between mucositis pain scores, tissue COX-1, and salivary prostaglandins in 4 patients receiving dose-dense chemotherapy. We investigated whether similar changes would be seen with radiotherapy (XRT)-induced mucositis. Methods: Patients receiving XRT including the oropharynx were evaluated at 4 time points, before XRT, midway through XRT, end of XRT, and 1 month after XRT. Subjective report of pain and objective mucositis scores were recorded. Patients also provided a 5-minute stimulated saliva specimen at each time point collected on ice with a protease inhibitor cocktail. Proteins were estimated using a Bradford assay. Prostaglandins were measured using ELISA assays. Results: 8 evaluable patients entered the study, including 7 male/1 female, median age 60 (range 48-66), primary site (oropharynx 1, unknown primary 1, base of tongue 3, tonsil 1, tongue 1, supraglottis 1), median XRT 7000 rads (range 6000-7200 rads), concomitant chemotherapy (cisplatin 7, none 1), histology (squamous 7, mucoepidermoid 1). Pain and mucositis scores increased during XRT and improved at 1 month after XRT. No increase in COX-2 levels was seen. Salivary PGD2, PGE2, and PGF2 increased from baseline with the greatest increase 1 month after XRT. There was a significant time effect for PGF2 (p=0.028) and marginal time effects for PGD2 (p=0.107) and PGE2 (p=0.069). Conclusions: Increased salivary prostaglandins are seen during and after XRT-induced oral mucositis, suggesting a role for proinflammatory mediators and providing a possible therapeutic target. Clinical trial information: NCT01252498. [Table: see text]

reviewed. All received neoadjuvant chemotherapy and mastectomy. Of them, 404 (77.2%) patients received postmastectomy radiotherapy (PMRT) and 119 (22.8%) not. 420(80.3%)had adjuvant chemotherapy. 289 out of 348 (83.0%) patients with ER and/or PR positive disease had hormone therapy. 67 out of 204 (32.8%) patients with Her2 positive disease had trastuzumab targeted therapy. The locoregional recurrence (LRR), diseasefree Survival (DFS) and overall survival (OS) rates were calculated using the Kaplan-Meier method, and differences were compared using the logrank test. Multivariate prognostic analysis was performed using the Cox regression model. Results: With a median follow up time of 66 months (range, 4-201 months), the 5-year LRR, DFS and OS were 16.3%, 61.4% and 82.1% respectively. For patients with and without PMRT, the 5-year LRR rates were 13.9% and 24.8%(P Z 0.013)，DFS were 64.1% and 53.9% (P Z 0.048)，and OS were 83.2% and 78.2%(P Z 0.389) respectively. In the subgroups of patients with ypT3-4, ypN2-3 and Stage III disease, PMRT significantly reduced LRR (P 0.01 for all comparisons)，and improved OS (P 0.003 for all comparisons). Of the 158 patients who achieved ypN0, the 5-year LRR rates were 1.0% and 12.4% (P Z 0.004)，DFS were 89.9% and 70.1%(pZ0.009)，and OS were 96.9% and 95.8%(P Z 0.802)for patients with and without PMRT. Of 41 patients who achieved pCR, 2 patients without PMRT developed LRR, whereas none of patients with PMRT had LRR (P Z 0.020). Multivariate analysis indicated that lack of PMRT was an independent prognostic factor associated with increased LRR and decreased DFS for all patients and ypN0 patients respectively. Conclusion: For patients with clinical stage IIIA and IIIB breast cancer treated with neoadjuvant chemotherapy and mastectomy, PMRT reduces LRR significantly for all patients, and reduces both recurrence and mortality risk for patients presenting with ypT3-4, ypN2-3 and pathologic stage III. PMRT might not be omitted safely for patients who achieved ypN0 or pCR, and further research is warranted.

ObjectivesTreatment for stage IA lung cancer may be too aggressive an approach in elderly patients with competing co-morbidities. We report outcomes for those electing active surveillance (AS) and investigate factors that may predict indolent disease.Materials and methodsRetrospective review was performed for 12 consecutive patients, ≥70 years old, with medically inoperable stage IA, T1N0M0 lung cancer and significant co-morbidities, who chose AS with radiation therapy (RT) reserved for clear disease progression. Collected data included Charlson-Deyo Comorbidity Index (CDCI) grades, histology, and tumor size changes. Volume doubling time (VDT) calculations used a modified Schwartz equation.ResultsFifteen nodules underwent AS in 12 patients; three patients had more than one nodule. Median age of all patients was 78 (range, 71–85). All patients’ CDCI grades were ≥1, 7 were ≥2. Eleven of 12 patients were deemed to be at high-risk for falls. Twelve nodules in 12 patients were biopsied; adenocarcinoma the prevailing common (47%) histology. The median, one, two and three year patient freedom-from-RT values were 21.4 months (95% CI: 11.6-not reached), 81%, 43%, and 29%, respectively. Median VDT of treated vs. untreated nodules was 189 days (range, 62-infinite) vs. 1153 days (range, 504-infinite), respectively. No patient progressed regionally or distantly, and there have been no cancer-related deaths. Due to cardiovascular events, two patients died and one remains on hospice. Median duration of AS for those still continuing computed tomography (CT) surveillance is 35.1 months.ConclusionSelected elderly patients with stage IA lung cancer and significant co-morbidities may undergo AS without detriment in outcome. Prospective AS studies are warranted.