The influence of extracorporeal photopheresis (ECP) in addition to total skin electron (TSE) therapy...
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Proceedings of the 40th Annual ASTRO Meeting 13 The Inlhmeace of Exiracorporeal Phnloldteresis (E('P) in Athliliou Io Total Skin Electron (THE) Thernpy on I)isease-Free and Cause-Specific Survival in Patients with Erythr0dermic iT4) My.costs Fnngoides (MF) and The Sezary Syndrome I.D WilsonMD..MPH.. ~GW JonesBSc,M.D.FR.C.P.MSc.. zD KimM D. ~ D RosenthalM.D,FR.CP., z I ChristensenB";.,R.N.'Rl..lidelsonM i),'PW I lcaldMi).;llM KacinskiMl),l~hl). ~'~ Department of Therapeutic Radiology. Yale University School of Medicine, New Haven. CT. USA] Ontario Cancer Treatment and Research Foundation. }talnilton. ( )llnlrio. ('anada 2 Depanlncnl of Derlrtatology. Yale University School of Medicine. New Haven. CT. USA ~ PurpnsetObjeeti',e: Superior efficacy ofF.CP conlhined with TSE as compared to TSli akmc has not been established for patients with T4 MF This study compares the disease-free (DFS), progression-flee (PFS), overall (OS), and cause-specific survivals (CSS) of patients receiving TSE plus neoadiuvant, concurrent and adjuvant ECP, to that of those receiving TSE alone. methnds and Materials: A total of 44 patients with erythrodermic (T4) MF (I lamilton, n:: [ 5, Yale, n-29) were treated between 1974 and 1997 with "modern TSE" (32-40Gy with 4-6MeV electrons, similar technique at both institutions). Twenty one of these patients received I~i( ;P as well. Median age was 68 yr (29-82), with 27% newly diagnosed, 34% female, 59% with hematological involvement 031), 30% stage IVA (N3), and 14% IVB, (M 1, pathologically confirmed) Therapy prior to TSE and TSE+ECP included a total of 75 courses which failed to control disease (15 systemic therapy, 16 biologicals, and 44 topicals). Seven patients received total skin doses of 32-35Gy, 11 received 35Gy, 25 received 36Gy, and 1 received 40Gy Median F/U was 22 yr (0.3-139) subsequent to TSE, and 37 yr from diagnosis (0 8-16 8) Ilesults: All patients responded to TSE with a cutaneous CR rate within 3 months 01"completion of 73% (32/44) For the 32 cotnplete esponders, the 3-yr DFS was 63% It was 49% for those 17 patients receiving only TSE versus 81% for the 15 patients receiving TSE+ECP Cox regression analysis reveals that ECP therapy was associated with prolonged remission (DFS multivariate p=O024, adjusting for B I and M 1) There were 49 subsequent courses of therapy for progression (20 chemotherapy, I 0 biologicals, and 19 topicals). Thirteen died from MF, and 6 died from other well defined causes The 2-yr PFS, CSS, and OS for the TSE alone group were 36%, 69%, and 63% compared to 66%, 100%, and 88% for the TSE+ECP group. Cox regression reveals that ECP was associa3ed with CSS (multivariate p=0.048, adjusting for B I and M 1) Acute and chronic toxicity were as previously reported Conclusions: ECP given concurrently, and/or immediately following TSE (32-40Gy) significantly improves both disease-free and cause- specific survival, as compared to results with modern TSE alone Combined modality therapy including TSE and ECP should therefore be considered for all erythrodermic iT4) patients with Mycosis Fungoides. 131 14 PSA FAILURE-FREE SURVIVAL FOLLOWING BRACHYTRERAPY OR EXTERNAL BEAM IRRADIATION FOR T1/T2 PROSTATE TUHORS IN 16OO PATIENTS: RESULTS FROM A SINGLE PRACTICE D. Brachman. H.D.~ D. Beyer. N.D. Arizona Oncology Services. Phoenix. Arizona PURPOSE: To evaluate PSA failure free survival for brachytherapy (BT) alone compared Co external beam radiotherapy (EBRT) alone for Stage TI, T2 patients treated over the same time period by a single community-based practice. NETHODS: The database of Arizona Ontology Services (a multi-physician radiation ontology practice in the Phoenix metropolitan area) was reviewed for patients meeting the following criteria: 1) T1 or T2 Nx-No Ho prostate cancer; 2) no prior or concurrent therapy including hormones; 3) treatment period 12/88-12/95 (12]88 corresponds Lo the start of the brachytherapy program); 4) treatment with either EBRT alone or BT alone (1-125 or Pd-lO3). This yielded q33 EBRT and 66q BT patients; no patients meeting the above criterion were excluded from analysis. Nedian follow up for ERRT patients is 30 months and for BT patients 46 months. Patients were not randomized to either therapy but rather received EBRT or BT based upon patient, treating and/or referring physician preference. PSA failure is defined according to the ASTRO consensus guidelines, RESULTS: The median patient age is 74 years for both groups. Number of Patients PSA Failure Free Survival at 60 No. EERT BT ERBT BT p TI 175 109 .80 .92 n.s. T2 758 560 .74 .72 n.s. Gleason 2-4 254 138 .77 .81 n.s. 5-6 408 409 .84 .79 n,s. 7 256 103 ,61 .51 .OOb PSA 0-4 96 124 .88 .86 n.s. ~4-10 339 327 .77 .79 n.s. >10-20 283 136 .79 .64 .007 )20 201 73 .60 .56 n.s. OVERALL 993 669 .74 .75 n.s. CONCLUSIONS: PSA Failure-Free Survivals are Kaplan-Neyer estimates at 60 months;p values refer to equality of survival curves (Hantel-Haenszel); n.s. = non significant. 1) In our patient population, either EBRT or BT appear equally efficacious for patients with T1/T2 diease with Gleason scores ~6 or PSA ~10; 2) patient~ wt~h presenting Gleason scores >7 or PSA >tO (but ~ 20) appear to fair significantly worse with BT alone compared to EBRT alone; 3) neither EBRT nor BT alone was particularly effective for patients with presenting PSA >20, as would we anticipated from the significant risk of occult distant metastasis in this group; 4) to our knowledge, this is the first report comparing the outcome of EBRT and BT treatment in patients treated concurrently by a single group; and 5) these results, achieved in a community-based practice, compare favorably to data from academic centers regarding external beam, brachytherapy or surgical outcomes and should be generalizable to the commuuitV at large.
Transcript of The influence of extracorporeal photopheresis (ECP) in addition to total skin electron (TSE) therapy...
Proceedings of the 40th Annual ASTRO Meeting
13 The Inlhmeace of Ex i racorporea l Phnloldteresis (E ( 'P ) in Athlil iou Io Tota l Skin Electron (THE) T h e r n p y on I) isease-Free and Cause-Speci f ic Surv iva l in Pat ients wi th E r y t h r 0 d e r m i c iT4) My.costs Fnngo ides ( M F ) and The Sezary S y n d r o m e
I.D W i l s o n M D . . M P H . . ~ G W J o n e s B S c , M . D . F R . C . P . M S c . . z D K i m M D . ~ D R o s e n t h a l M . D , F R . C P . , z I C h r i s t e n s e n B " ; . , R . N . ' R l . . l i d e l s o n M i ) , ' P W I l c a l d M i ) . ; l l M K a c i n s k i M l ) , l ~ h l ) . ~'~ Department of Therapeutic Radiology. Yale University School of Medicine, New Haven. CT. USA] Ontario Cancer Treatment and Research Foundation. }talnilton. ( )llnlrio. ('anada 2 Depanlncnl of Derlrtatology. Yale University School of Medicine. New Haven. CT. USA ~
PurpnsetObjeeti ' ,e: Superior efficacy ofF.CP conlhined with TSE as compared to TSli akmc has not been established for patients with T4
MF This study compares the disease-free (DFS), progression-flee (PFS), overall (OS), and cause-specific survivals (CSS) of patients
receiving TSE plus neoadiuvant, concurrent and adjuvant ECP, to that of those receiving TSE alone.
methnds and Materials: A total o f 44 patients with erythrodermic (T4) MF (I lamilton, n:: [ 5, Yale, n -29) were treated between 1974 and
1997 with "modern TSE" (32-40Gy with 4-6MeV electrons, similar technique at both institutions). Twenty one of these patients received
I~i( ;P as well. Median age was 68 yr (29-82), with 27% newly diagnosed, 34% female, 59% with hematological involvement 031), 30% stage
IVA (N3), and 14% IVB, (M 1, pathologically confirmed) Therapy prior to TSE and TSE+ECP included a total o f 75 courses which failed
to control disease (15 systemic therapy, 16 biologicals, and 44 topicals). Seven patients received total skin doses of 32-35Gy, 11 received
35Gy, 25 received 36Gy, and 1 received 4 0 G y Median F/U was 2 2 yr (0 .3-139) subsequent to TSE, and 3 7 yr from diagnosis (0 8-16 8)
I lesults: All patients responded to TSE with a cutaneous CR rate within 3 months 01"completion of 73% (32/44) For the 32 cotnplete
esponders, the 3-yr DFS was 6 3 % It was 49% for those 17 patients receiving only TSE versus 81% for the 15 patients receiving T S E + E C P
Cox regression analysis reveals that ECP therapy was associated with prolonged remission (DFS multivariate p=O024, adjusting for B I and
M 1) There were 49 subsequent courses of therapy for progression (20 chemotherapy, I 0 biologicals, and 19 topicals). Thirteen died from
MF, and 6 died from other well defined causes The 2-yr PFS, CSS, and OS for the TSE alone group were 36%, 69%, and 63% compared
to 66%, 100%, and 88% for the TSE+ECP group. Cox regression reveals that ECP was associa3ed with CSS (multivariate p=0.048,
adjusting for B I and M 1 ) Acute and chronic toxicity were as previously repor ted
Conclus ions : ECP given concurrently, and/or immediately following TSE (32-40Gy) significantly improves both disease-free and cause-
specific survival, as compared to results with modern TSE alone Combined modality therapy including TSE and ECP should therefore be
considered for all erythrodermic iT4) patients with Mycosis Fungoides.
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14 PSA FAILURE-FREE SURVIVAL FOLLOWING BRACHYTRERAPY OR EXTERNAL BEAM IRRADIATION FOR T1/T2 PROSTATE TUHORS IN 16OO PATIENTS: RESULTS FROM A SINGLE PRACTICE
D. Brachman. H.D.~ D. Beyer . N.D.
A r i z o n a Onco logy S e r v i c e s . P h o e n i x . A r i z o n a
PURPOSE: To e v a l u a t e PSA f a i l u r e f r e e s u r v i v a l f o r b r a c h y t h e r a p y (BT) a lone compared Co e x t e r n a l beam r a d i o t h e r a p y (EBRT) a lone f o r Stage T I , T2 p a t i e n t s t r e a t e d ove r t h e same t i m e p e r i o d by a s i n g l e commun i t y -based p r a c t i c e .
NETHODS: The d a t a b a s e of A r i z o n a Onto logy S e r v i c e s (a m u l t i - p h y s i c i a n r a d i a t i o n o n t o l o g y p r a c t i c e in t he Phoen ix m e t r o p o l i t a n a r e a ) was r e v i e w e d f o r p a t i e n t s m e e t i n g the f o l l o w i n g c r i t e r i a : 1) T1 or T2 Nx-No Ho p r o s t a t e c a n c e r ; 2) no p r i o r o r c o n c u r r e n t t h e r a p y i n c l u d i n g hormones; 3) t r e a t m e n t p e r i o d 12 /88 -12 /95 (12]88 c o r r e s p o n d s Lo the s t a r t of t he b r a c h y t h e r a p y p r o g r a m ) ; 4) t r e a t m e n t w i t h e i t h e r EBRT a lone or BT a lone (1-125 o r P d - l O 3 ) . T h i s y i e l d e d q33 EBRT and 66q BT p a t i e n t s ; no p a t i e n t s m e e t i n g the above c r i t e r i o n were e x c l u d e d from a n a l y s i s . Nedian f o l l o w up f o r ERRT p a t i e n t s i s 30 months and f o r BT p a t i e n t s 46 months . P a t i e n t s were not randomized to e i t h e r t h e r a p y but r a t h e r r e c e i v e d EBRT or BT based upon p a t i e n t , t r e a t i n g a n d / o r r e f e r r i n g p h y s i c i a n p r e f e r e n c e . PSA f a i l u r e i s d e f i n e d a c c o r d i n g to the ASTRO c o n s e n s u s g u i d e l i n e s ,
RESULTS: The median p a t i e n t age i s 74 y e a r s f o r both g r o u p s .
Number of P a t i e n t s PSA F a i l u r e Free S u r v i v a l a t 60 No. EERT BT ERBT BT p
TI 175 109 .80 .92 n . s . T2 758 560 .74 .72 n . s . G leason 2-4 254 138 .77 .81 n . s .
5-6 408 409 .84 .79 n , s . 7 256 103 ,61 .51 .OOb
PSA 0 - 4 96 124 .88 .86 n . s . ~4 -10 339 327 .77 .79 n . s .
>10-20 283 136 .79 .64 .007 ) 2 0 201 73 .60 .56 n . s .
OVERALL 993 669 .74 .75 n.s.
CONCLUSIONS:
PSA F a i l u r e - F r e e S u r v i v a l s a re K a p l a n - N e y e r e s t i m a t e s a t 60 m o n t h s ; p v a l u e s r e f e r t o e q u a l i t y of s u r v i v a l c u r v e s ( H a n t e l - H a e n s z e l ) ; n . s . = non s i g n i f i c a n t .
1) In our p a t i e n t p o p u l a t i o n , e i t h e r EBRT or BT a p p e a r e q u a l l y e f f i c a c i o u s f o r p a t i e n t s w i t h T1/T2 d i e a s e w i t h Gleason s c o r e s ~ 6 or PSA ~10 ; 2) p a t i e n t ~ wt~h p r e s e n t i n g G l e a s o n s c o r e s >7 or PSA >tO ( b u t ~ 20) a p p e a r to f a i r s i g n i f i c a n t l y worse w i t h BT a lone compared to EBRT a l o n e ; 3) n e i t h e r EBRT nor BT a lone was p a r t i c u l a r l y e f f e c t i v e f o r p a t i e n t s w i t h p r e s e n t i n g PSA > 2 0 , as would we a n t i c i p a t e d f rom t h e s i g n i f i c a n t r i s k of o c c u l t d i s t a n t m e t a s t a s i s in t h i s g roup ; 4) to our knowledge , t h i s i s t he f i r s t r e p o r t c o m p a r i n g the outcome of EBRT and BT t r e a t m e n t in p a t i e n t s t r e a t e d c o n c u r r e n t l y by a s i n g l e g roup ; and 5) t h e s e r e s u l t s , a c h i e v e d in a communi ty -based p r a c t i c e , compare f a v o r a b l y to d a t a f rom academic c e n t e r s r e g a r d i n g e x t e r n a l beam, b r a c h y t h e r a p y o r s u r g i c a l ou tcomes and shou ld be g e n e r a l i z a b l e to the commuuitV at l a r g e .
