Showing papers by "Prajnan Das published in 2015"

Esophageal and esophagogastric junction cancers, version 1.2015.

Abstract: Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Adenocarcinoma is more common in North America and Western European countries, originating mostly in the lower third of the esophagus, which often involves the esophagogastric junction (EGJ). Recent randomized trials have shown that the addition of preoperative chemoradiation or perioperative chemotherapy to surgery significantly improves survival in patients with resectable cancer. Targeted therapies with trastuzumab and ramucirumab have produced encouraging results in the treatment of advanced or metastatic EGJ adenocarcinomas. Multidisciplinary team management is essential for patients with esophageal and EGJ cancers. This portion of the NCCN Guidelines for Esophageal and EGJ Cancers discusses management of locally advanced adenocarcinoma of the esophagus and EGJ.

Paraneoplastic thrombocytosis independently predicts poor prognosis in patients with locally advanced pancreatic cancer

Abstract: Background and aims. Platelets are believed to promote tumor growth and metastasis but their prognostic role in locally advanced pancreatic cancer (LAPC) remains largely unknown. We assessed whether pretreatment platelet counts independently predict survival outcomes in patients with LAPC treated with chemoradiation (CRT).Methods. We retrospectively reviewed the MD Anderson pancreatic cancer database and identified 199 patients with LAPC treated with CRT between 2006 and 2012. Induction chemotherapy was used prior to consolidative CRT in 177 (89%) patients. Median radiation dose was 50.4 Gy. Concurrent radiosensitizers were gemcitabine-based (13%) or capecitabine-based (84%) regimens. Actuarial univariate and multivariate statistical methods were used to determine significant prognostic factors for overall survival (OS) and progression-free survival (PFS) calculated from the start of treatment.Results. Median follow-up was 9.9 months. Median OS and PFS durations were 17.7 and 10.7 months, respecti...

Long-Term Outcomes of Adding HPV Vaccine to the Anal Intraepithelial Neoplasia Treatment Regimen in HIV-Positive Men Who Have Sex with Men

Abstract: Background. Recent evidence shows that quadrivalent human papillomavirus (qHPV) vaccination in men who have sex with men (MSM) who have a history of high-grade anal intraepithelial neoplasia (HGAIN) was associated with a 50% reduction in the risk of recurrent HGAIN. We evaluated the long-term clinical and economic outcomes of adding the qHPV vaccine to the treatment regimen for HGAIN in human immunodeficiency virus (HIV)–positive MSM aged ≥27 years. Methods. We constructed a Markov model based on anal histology in HIV-positive MSM comparing qHPV vaccination with no vaccination after treatment for HGAIN, the current practice. The model parameters, including baseline prevalence, disease transitions, costs, and utilities, were either obtained from the literature or calibrated using a natural history model of anal carcinogenesis. The model outputs included lifetime costs, quality-adjusted life years, and lifetime risk of developing anal cancer. We estimated the incremental cost-effectiveness ratio of qHPV vaccination compared to no qHPV vaccination and decrease in lifetime risk of anal cancer. We also conducted deterministic and probabilistic sensitivity analyses to evaluate the robustness of the results. Results. Use of qHPV vaccination after treatment for HGAIN decreased the lifetime risk of anal cancer by 63% compared with no vaccination. The qHPV vaccination strategy was cost saving; it decreased lifetime costs by $419 and increased quality-adjusted life years by 0.16. Results were robust to the sensitivity analysis. Conclusions. Vaccinating HIV-positive MSM aged ≥27 years with qHPV vaccine after treatment for HGAIN is a cost-saving strategy. Therefore, expansion of current vaccination guidelines to include this population should be a high priority.

Predictors of Survival in Patients with Resectable Gastric Cancer Treated with Preoperative Chemoradiation Therapy and Gastrectomy.

Abstract: Background The purpose of this study was to determine the overall survival (OS) of patients with resectable gastric cancer treated with preoperative chemoradiation therapy and gastrectomy. Study Design The medical records of patients with gastric adenocarcinoma presenting to our institution (January 1995 to August 2012) were reviewed to identify patients who underwent diagnostic laparoscopy, preoperative chemoradiation, and gastrectomy. Associations between various clinicopathologic factors and OS were examined with Cox proportional hazards models. Results Of 192 patients who met inclusion criteria, 103 (54%) required total gastrectomy. One hundred sixty-eight patients (88%) had an extended lymph node dissection, 26 (14%) had resection of adjacent organs, and 178 (93%) had an R0 resection. Median follow-up time for surviving patients was 4.2 years. Median OS for all patients was 5.8 years, and 5-year OS rate was 56%. Multivariable Cox regression model results identified variables associated with diminished OS including age ≥ 65 years (hazard ratio [HR] 1.62; 95% CI 1.05 to 2.51), male sex (HR 1.76; 95% CI 1.13 to 2.74), adjacent organ resection (HR 1.97; 95% CI 1.16 to 3.35), R1 status (HR 2.29; 95% CI 1.17 to 4.48), pathologic N1 stage (HR 1.92; 95% CI 1.24 to 2.98), N2 stage (HR 2.58; 95% CI 1.01 to 6.58), and N3 stage (HR 6.54; 95% CI 2.69 to 15.93). Five-year OS rates for patients with pathologic N0, N1, N2, and N3 disease were 67%, 42%, 43%, and 0%, respectively. Conclusions Patients with gastric cancer who undergo diagnostic laparoscopy, preoperative chemoradiation, and gastrectomy have a high frequency of obtaining an R0 resection and excellent OS rates. Nodal status after surgery remains an important determinant of OS.

Molecular biomarkers in gastric cancer.

Abstract: Gastric cancer (GC) represents a serious health problem on a global scale. Despite some recent advances in the field, the prognosis in metastatic GC remains poor. Even in localized disease the adjunctive therapies improve overall survival (OS) by only approximately 10%. A better understanding of molecular biology, which would lead to improved treatment options, is needed and is the basis for this review. Many potential biomarkers of prognostic significance have been identified, including ALDH, SHH, Sox9, HER2, EGFR, VEGF, Hippo/YAP, and MET. However, inhibition of only HER2 protein has led to a modest survival benefit. A new approach to GC treatment, which is a disease influenced by inflammation, is the exploitation of the immune system to fight disease. Two interesting targets/prognostic markers that bear further investigation in GC are PD1 and PDL, particularly given their success in the treatment of other inflammation/immune-associated malignancies.

Clinicopathologic Features Associated With Human Papillomavirus/p16 in Patients With Metastatic Squamous Cell Carcinoma of the Anal Canal.

Abstract: Background The incidence of anal carcinoma in the U.S. continues to increase steadily, and infection with the human papillomavirus (HPV) is an established risk factor for the development of anal carcinoma. However, the clinicopathologic characteristics of patients with metastatic squamous cell carcinoma of the anal canal according to HPV status have not yet been defined. Materials and methods The records of patients treated for metastatic squamous cell carcinoma of the anal canal at the MD Anderson Cancer Center from June 2005 to August 2013 were reviewed. The patients were tested for the presence of HPV DNA by in situ hybridization and/or the p16 oncoprotein by immunohistochemistry. Associations between the presence of HPV and clinicopathologic attributes were measured. Results Of the 72 patients reviewed, 68 tumors (94%) had detectable HPV. Patients with HPV-negative tumors were more likely to be of nonwhite ethnicity (odds ratio, 8.7) and have a strong (>30 pack-year) tobacco history (odds ratio, 8.7). A trend toward improved survival from the time of diagnosis of metastatic disease was noted among patients with HPV-positive tumors. Conclusion Most patients with metastatic anal cancer had detectable HPV, with differences in tobacco history and ethnicity detected according to HPV status. The high frequency of HPV positivity for patients with metastatic anal cancer has important implications for novel immunotherapy treatment approaches, including ongoing clinical trials with immune checkpoint blockade agents using antibodies targeting the programmed death-1 receptor. Implications for practice Previous studies investigating the clinical features of patients with anal cancer focused on those with early-stage disease. The present study characterizes, for the first time, clinical and pathological features according to human papillomavirus (HPV) status for patients with metastatic anal cancer. A high frequency of HPV-positive tumors and correlations between HPV status and both ethnicity and tobacco history was found. No standard-of-care therapy is available for patients with metastatic anal cancer, and most receive cytotoxic chemotherapy. The high prevalence of HPV in the current population generates optimism for ongoing clinical trials investigating the role of immune checkpoint blockade agents as a novel treatment approach for this disease.

Comprehensive geriatric assessment in patients with gastric and gastroesophageal adenocarcinoma undergoing gastrectomy.

Abstract: Objective The purpose of this study was to identify clinical and geriatric assessment variables associated with outcome in patients with gastric adenocarcinoma who have undergone gastrectomy. Methods We reviewed demographic, clinical, and geriatric assessment variables, including recent falls, pain, performance status, American Society of Anesthesiologists score, assistive device use, comorbidity, polypharmacy, and weight change, for patients undergoing gastrectomy between 2005 and 2014. Outcome variables included morbidity, mortality, hospital length of stay, and readmission. Results Of 279 patients, 133 (48%) underwent total gastrectomy. The 90-day major morbidity rate was 24% and the mortality rate was 1%. Length of hospital stay ≥14 days occurred in 38%, with readmission within 30 days in 13%. On multivariate analysis, gastroesophageal junction involvement, (odds ratio [OR] 2.5, 95% confidence interval [1.1–5.8]), additional organ resection, (OR 3.2, [1.6–6.3]), pain score >0 (OR 3.8, [1.6–8.7]), Eastern Cooperative Oncology Group performance status >0, (OR 2.3, [1.2–4.6]), and polypharmacy (OR 2.4, [1.1–5.2]) were associated with major morbidity. Hospital stay ≥14 days was associated with age ≥75 years (OR 3.9, [1.7–9.2]), total gastrectomy (OR 3.5, [2.0–6.3]), performance status >0 (OR 1.8, [1.0–3.2]), and preoperative chemotherapy (OR 0.3, [0.2–0.7]). Conclusions Future studies are needed to identify methods to improve performance status, as this may improve postoperative complications and resource utilization. J. Surg. Oncol. © 2015 Wiley Periodicals, Inc.

Total Lifetime and Cancer-related Costs for Elderly Patients Diagnosed With Anal Cancer in the United States

Abstract: Objective To determine the lifetime and phase-specific cost of anal cancer management and the economic burden of anal cancer care in elderly (66 y and older) patients in the United States. Patients and methods For this study, we used Surveillance Epidemiology and End Results-Medicare linked database (1992 to 2009). We matched newly diagnosed anal cancer patients (by age and sex) to noncancer controls. We estimated survival time from the date of diagnosis until death. Lifetime and average annual cost by stage and age at diagnosis were estimated by combining survival data with Medicare claims. The average lifetime cost, proportion of patients who were elderly, and the number of incident cases were used to estimate the economic burden. Results The average lifetime cost for patients with anal cancer was US$50,150 (N=2227) (2014 US dollars). The average annual cost in men and women was US$8025 and US$5124, respectively. The overall survival after the diagnosis of cancer was 8.42 years. As the age and stage at diagnosis increased, so did the cost of cancer-related care. The anal cancer-related lifetime economic burden in Medicare patients in the United States was US$112 million. Conclusions Although the prevalence of anal cancer among the elderly in the United States is small, its economic burden is considerable.

Factors associated with radiation therapy incidents in a large academic institution

Abstract: Background This study evaluated factors associated with radiation therapy (RT) planning and delivery incidents at a large academic institution. Methods and materials The RT incidents (including near-misses) were recorded using an electronic incident reporting system from April 1, 2011 to April 30, 2013. Each incident's origin was categorized according to the step in the treatment process (simulation, physician prescription, treatment planning, scheduling, treatment delivery, and other) in which it occurred. The incident database was linked to the RT delivery (record and verify) database to evaluate the effect of various factors on the rate of RT incidents. Results There were 189 reported RT incidents (including near-misses) among 326,448 fractions, of which there were 70 (37%) treatment planning incidents and 56 (30%) treatment delivery incidents. The rates of total incidents, planning incidents, and delivery incidents were 136.0, 50.4, and 40.3 per 10,000 patients, respectively. Logistic multivariate analysis showed that fewer work days from plan approval to treatment start, fewer fractions, higher number of prescription items, and longer beam duration were significantly associated with radiation planning incidents. Multivariate analysis also showed that first day of treatment, fewer fractions, higher number of prescription items, and longer beam duration were significantly associated with treatment delivery incidents; intensity modulated radiation therapy was associated with a lower rate of treatment delivery incidents. Conclusions More complicated radiation plans, fewer fractions, first day of treatment, and rushed processes were associated with higher risk of RT incidents. We hope that a national incident reporting database will lead to greater understanding of factors influencing the rate of RT incidents.

Taking “the Game” Out of The Match: A Simple Proposal

Abstract: *Residency Program, Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York; yResidency Program, Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; zResidency Program, Radiation Oncology, University of Chicago Medical Center, Chicago, Illinois; xRadiation Oncology Residency and Fellowship Program, M. D. Anderson Cancer Center, Houston, Texas; jjResidency Program, Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut; {Residency Program, Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland; and Residency Program, Harvard Radiation Oncology Program, Boston, Massachusetts

Medical student perspectives on a multi-institutional clerkship curriculum: A report from the radiation oncology education collaborative study group

Abstract: Medical students applying for radiation oncology residency rated “perceived quality of didactics” within the top 5 factors in ranking programs (1). However, according to a 2013 national survey, only 27% of radiation oncology clerkships included didactic components specifically for medical students (2). In 2012, a pilot radiation oncology clerkship curriculum was developed at two institutions using the six-step conceptual framework for medical education curriculum development by Kern et al (3). Eighteen students completed the pilot curriculum. Students rated the curriculum highly and reported improved comfort with their decision to pursue radiation oncology as a specialty (4). Using the cooperative group research model, the curriculum was expanded to 11 selected academic medical centers within the United States in 2013 with the goal of increasing the number of participating students to provide more robust feedback for further curriculum development. Here, we describe the structure of the curriculum with corollary student feedback that can be used by other institutions to design or enhance their medical student curriculum. The curriculum consisted of three 1-hour lectures delivered by a senior resident or faculty member; topics included: (1) an overview of radiation oncology, including a history of the specialty, types of treatments, and basic clinic flow; (2) fundamentals of radiation biology and radiation physics; and (3) practical aspects of radiation treatment simulation and planning and radiation emergencies. Ideally, one session was conducted per week with all students present. The lecture format was open, and students were encouraged to ask questions. In addition, a 1-hour hands-on radiation treatment workshop facilitated by a senior resident, faculty, physicist, or dosimetrist was implemented to teach students the fundamentals of radiation treatment planning (5). While using a radiation treatment planning workstation, each student was provided with a step-by-step guide to delineating a radiation target, selecting appropriately directed radiation beams, and modifying various beam parameters to achieve an optimal plan. Individual institutions were encouraged to adapt the lectures according to institutional treatment or practice patterns, but all institutions retained the core curriculum format (3 lectures, 1 planning session). All participating institutions obtained institutional review board exemption. A total of 94 students participated in the curriculum in the 2013 academic year, allowing both wide dissemination and robust feedback. Upon completion of the clerkship, students were invited to complete an anonymous internet-based survey to rate the curriculum components, which yielded a 73% response rate. Qualitative analysis of the evaluations was undertaken by two authors (P.M. and J.C.Y.). Evaluation-free responses were reviewed independently and divided into positive and negative “consistent” themes (Table 1). These themes reflected the students' subjective overall feeling that the course laid an excellent knowledge foundation for transition to residency and their concern that they might not retain the knowledge during the two years prior to beginning residency. Future directions for curriculum development include expansion to additional institutions while using these constructive comments to enhance the learning experience. For example, one negative theme was that lectures should be scheduled earlier in the rotation to ensure that students have a good knowledge base for the remainder of the clinical rotation. This and other constructive feedback will be considered in the future when implementing the curriculum. Table 1 Consistent positive and negative feedback themes for individual curriculum components and how the curriculum will or will not be useful for transition to residency and for the overall curriculum This successful implementation of a standardized curriculum piloted at multiple institutions provides proof-of-principle that curriculum development can follow the multi-institutional cooperative group model. In the process, we identified areas of positive and negative needs as perceived by the students, who represent the most important stakeholders. Additional data are being collected to assess the impact of this curriculum on the students' decision to apply for radiation oncology residency. In the interim, the current data can help individual departments enhance their ongoing curriculum for rotating medical students.

Incidence and predictors of chest wall toxicity after high-dose radiation therapy in 15 fractions

Abstract: Purpose Fifteen fraction treatment schedules are increasingly used to deliver high doses of radiation therapy (RT) to both lung and hepatobiliary malignancies. The purpose of our study was to examine the incidence and predictors of chest wall (CW) toxicity in patients treated with this regimen. Methods and materials We evaluated 135 patients treated with RT to doses ≥52.5 Gy in 15 fractions for thoracic and hepatobiliary malignancies between January 2009 and December 2012. We documented patient characteristics and CW dosimetric parameters for each case. Toxicity was scored using the Common Terminology Criteria for Adverse Events, version 4.0, criteria for radiation dermatitis and CW pain. Patient characteristics and CW dosimetric parameters were evaluated for their association with CW toxicity using proportional hazards regression. Results Median follow-up was 9 months from the start of RT. Forty-eight patients (36%) developed dermatitis at a median time of 18 days. In multivariable analysis, the absolute volume of CW (in cm 3 ) receiving 40 Gy (V40) ≥120 cm 3 was associated with the occurrence of dermatitis (hazard ratio, 3.12; 95% confidence interval, 1.74-5.60; P 3 was associated with the occurrence of CW pain (hazard ratio, 2.65; 95% confidence interval, 1.12-6.24; P = .03). The absolute rate of CW pain in patients with V40 3 was 11% versus 26% in patients with V40 ≥150 cm 3 ( P = .03). Conclusions Hypofractionated RT with 15 fraction regimens results in an acceptable incidence of CW toxicity, specifically CW pain. We recommend a dose constraint of V40 3 to minimize this adverse event.

Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma.

Abstract: 362 Background: Patients with high risk resectable and borderline resectable pancreatic adenocarcinoma (BRPC) are at a high risk for R1/R2 resection, early relapse with upfront surgery and poor OS. Preop therapy has a sound rationale and current retrospective data suggest resection rates of 40-60% with a possible impact on OS. Methods: We planned a prospective study of 33 pts. Eligibility includes diagnosis of pancreatic ductal carcinoma (PC) and >=1 criteria of BRPC (radiographic) A: (i) PC involves SMV with vein deformity or segmental occlusion; (ii) PC involves =500 mg/dl (v) malignant peripancreatic nodes outside planned surgical field (vi) indeterminate liver or peritoneal lesions. Enrolled pts receive mFOLFIRINOX (oxaliplatin 75 mg/m2 d1+ irinotecan 150 mg/m2 d1+ 5-FU 2000mg/m2 46h CI) for 6 cycles. Those without progression & good PS undergo EBRT 50.4Gy with weekly Gemcitabine 350 m...

Quality of life after intensity-modulated radiation therapy for anal cancer

Abstract: The aim of this study was to evaluate quality of life after intensity-modulated radiation therapy (IMRT) for anal cancer. Between 2007 and 2011, 63 patients with anal cancer were treated with IMRT and concurrent chemotherapy, and achieved complete response. These patients completed Functional Assessment of Cancer Therapy-Colorectal (FACT-C) and Medical Outcomes Study Sexual Problems Scale (MOS-SPS) questionnaires during follow-up visits. Thirty-four patients (54 %) answered at least one questionnaire. Among them, the median radiation dose was 54 Gy to the tumor and 45 Gy to the pelvis. The median interval between treatment and the latest questionnaire was 33 months. On the latest questionnaires, the median total FACT-C score was 111, out of maximum (best possible) score 136. The median scores on the Physical, Social/Family, Emotional Functional, and Colorectal subscales were 24, 24, 19, 21, and 21, out of maximum (best possible) scores 28, 28, 24, 28 and 28, respectively. The median score on the MOS Sexual Problems Scale was 62, out of maximum (worst possible) score 100. Patients with lymph node involvement reported worse total FACT-C scores (p = 0.048), as well as worse Social/Family (p = 0.026) and Emotional (p = 0.032) subscale scores. A history of depression/anxiety was significantly associated with worse Physical (p = 0.034) and Emotional (p = 0.003) subscale scores. The use of vaginal dilator during treatment significantly improved Social/Family subscale scores (p = 0.031). Overall quality of life scores were acceptable, but sexual functioning scores were suboptimal after IMRT for anal cancer.

Internal respiratory surrogate in multislice 4D CT using a combination of Fourier transform and anatomical features

Abstract: Purpose: The purpose of this study was to develop a novel algorithm to create a robust internal respiratory signal (IRS) for retrospective sorting of four-dimensional (4D) computed tomography (CT) images Methods: The proposed algorithm combines information from the Fourier transform of the CT images and from internal anatomical features to form the IRS The algorithm first extracts potential respiratory signals from low-frequency components in the Fourier space and selected anatomical features in the image space A clustering algorithm then constructs groups of potential respiratory signals with similar temporal oscillation patterns The clustered group with the largest number of similar signals is chosen to form the final IRS To evaluate the performance of the proposed algorithm, the IRS was computed and compared with the external respiratory signal from the real-time position management (RPM) system on 80 patients Results: In 72 (90%) of the 4D CT data sets tested, the IRS computed by the authors’ proposed algorithm matched with the RPM signal based on their normalized cross correlation For these data sets with matching respiratory signals, the average difference between the end inspiration times (Δt ins) in the IRS and RPM signal was 011 s, and only 21% of Δt ins were more than 05 s apart In the eight (10%) 4D CT data sets in which the IRS and the RPM signal did not match, the average Δt ins was 073 s in the nonmatching couch positions, and 354% of them had a Δt ins greater than 05 s At couch positions in which IRS did not match the RPM signal, a correlation-based metric indicated poorer matching of neighboring couch positions in the RPM-sorted images This implied that, when IRS did not match the RPM signal, the images sorted using the IRS showed fewer artifacts than the clinical images sorted using the RPM signal Conclusions: The authors’ proposed algorithm can generate robust IRSs that can be used for retrospective sorting of 4D CT data The algorithm is completely automatic and requires very little processing time The algorithm is cost efficient and can be easily adopted for everyday clinical use

Early versus Delayed Therapy of Advanced Gastric Cancer Patients--Does It Make a Difference?

Abstract: Background: Nearly 50% of gastric cancer patients are diagnosed with advanced gastric cancer (AGC). Therapy is palliative but results in ill effects. The median o

Initial standardized uptake value of positron emission tomography influences the prognosis of patients with localized gastric adenocarcinoma treated preoperatively

Abstract: Background: In patients with localized gastric adenocarcinoma (LGAC) who receive preoperative therapy, tools to predict response or prognosticate outcome before t

Prognosis of gastric cancer (GC) patients with positive peritoneal cytology.

Abstract: 41 Background: Laparoscopic staging of patients with GC can disclose peritoneal metastases. Although this finding is associated with a poor prognosis, some patients achieve a long-term survival. In an attempt to provide explanation we compared the overall survival (OS) of patients with GC peritoneal metastases from two settings: cytology positive only (Cy+) and grossly positive (Gross+). Methods: 146 GC patients with peritoneal metastases were identified between 2000 and 2014. Cox-model regression was used for overall survival (OS) analyses. Results: Patient/treatment characteristics were as follows: males (66%), good ECOG scores (0-1; 89%), metastases confirmed by a diagnostic laparoscopy (84%), poorly differentiated histology(92%), received chemotherapy (89%), received chemoradiation (22%), and received surgery (10%). The median follow-up time for all patients was 12.9 months and median OS was 15 months. Patients with Gross+ were at higher risk of death compared to Cy+ patients (50% vs. 83%1-year OS, re...

ACR Appropriateness Criteria® Resectable Stomach Cancer

Abstract: For resectable gastric cancer, perioperative chemotherapy or adjuvant chemoradiation with chemotherapy are standards of care. The decision making for adjuvant therapeutic management can depend on the stage of the cancer, lymph node positivity, and extent of surgical resection. After gastric cancer resection, postoperative chemotherapy combined with chemoradiation should be incorporated in cases of D0 lymph node dissection, positive regional lymph nodes, poor clinical response to induction chemotherapy, or positive margins. In the setting of a D2 lymph node dissection, especially those with negative regional lymph nodes, adjuvant chemotherapy alone could be considered. The American College of Radiology (ACR) Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review includes an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® Local Excision in Early Stage Rectal Cancer.

Abstract: Low anterior resection or abdominoperineal resection are considered standard treatments for early rectal cancer but may be associated with morbidity in selected patients who are candidates for early distal lesions amenable to local excision (LE). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The panel recognizes the importance of accurate staging to identify patients who may be candidates for a LE approach. Patients who may be candidates for LE alone include those with small, low-lying T1 tumors, without adverse pathologic features. Several surgical approaches can be utilized for LE however none include lymph node evaluation. Adjuvant radiation±chemotherapy may be warranted depending on the risk of nodal metastases. Patients with high-risk T1 tumors, T2 tumors not amenable to radical surgery may also benefit from adjuvant treatment; however, patients with positive margins or T3 lesions should be offered abdominoperineal resection or low anterior resection. Neoadjuvant radiation±chemotherapy followed by LE in higher risk patients results in excellent local control, but it is not clear if this approach reduces recurrence rates over surgery alone.

Signet ring cell (SRC) histology of localized gastric adenocarcinoma (LGAC) to predict response to preoperative chemoradiation.

Abstract: 4067 Background: Patients with LGAC, when treated with preoperative therapy, have heterogeneous and unpredictable outcomes. Currently, there are no clinical variables or biomarkers that can predict...

Effect of dose-escalation of IMRT for unresectable pancreatic cancer 1 cm away from the luminal mucosa on long-term survival.

Abstract: 354 Background: The use of chemoradiation (CXRT) for locally advanced pancreatic cancer (LAPC) is controversial. Delivery of high doses of RT capable of leading to local tumor control is challenging. We reviewed outcomes of treatement with dose-escalated IMRT with curative intent. Methods: Of 211 patients treated from 5/2006 to 8/2014 with CXRT for LAPC, 49(23%) had tumors > 1 cm from the luminal organs ere selected for dose-escalated IMRT using integrated boost (SIB) technique, inspiration breath hold, and computed tomographic (CT) image guidance. Fractionation was optimized for coverage of gross tumor (GTV,Table 1). A 2-5mm margin on the GTV, was treated as an SIB within a microscopic dose. Forty-seven (96%) patients received a median of 4.0 months of induction chemotherapy and 45 (92%) received concurrent capecitabine or gemcitabine. Results: Mean GTV coverage was 86% (95% CI 78% to 94%). Median FU was 32 mo. Median OS and 1, 2, 3 and 5 year OS rates were 22.6mo (95% CI 16.4 to 43.9mo), 83%, 49%,38%, a...

Characterization of unresectable cholangiocarcinoma patients treated with or without chemoradiation.

Abstract: 403 Background: Curative treatment for cholangiocarcinoma (CC) is surgical resection. Unfortunately, most CC patients (pts) present with unresectable disease in which gemcitabine plus platinum (GEM-P) chemotherapy is the mainstay of treatment (tx). Advanced CC has a dismal prognosis with 5-year survival reported at 5-10 %. Data regarding chemoradiation (CRT) in pts with unresectable CC (uCC) remains limited. Methods: We retrospectively reviewed uCC pts from 1/1/2009 to 7/31/2013. Primary objective: to evaluate the percentage of pts treated with CRT and the median number of chemotherapy cycles given prior to CRT. Secondary objectives: response to first-line tx, progression free survival (PFS) with or without CRT, overall survival (OS) with or without CRT, and duration of CRT control. Inclusion criteria: uCC diagnosis, received tx, and had follow-up at our institution. Exclusion criteria: pts who received liver-directed therapy other than CRT, mixed histology tumors, and a history of other malignancies. Res...