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S30 International Journal of Radiation Oncology  Biology  Physics

evaluable patients were excluded from further analysis. Toxicities were and W. Bosch10; 1Brigham & Women’s Hospital/Dana-Farber Cancer
scored by CTC v 3.0. LAP07 final analysis will be done in March 2013. Institute, Boston, MA, 2Medical College of Wisconsin, Milwaukee,
Results: Among the 442 included patients, 135 patients have been WI, 3University of Pittsburgh Cancer Institute, Pittsburgh, PA,
randomized in the CRT arm. Fifteen patients did not receive CRT. Five London Health Sciences Centre and Western University, London,
patients were not evaluable. RTQAs of the 115 patients were 24% PP, 50% ON, Canada, 5University of North Carolina, Chapel Hill, NC,
MID and 16% MAD. MAD were mainly PTV coverage inhomogeneities Miller School of Medicine, Miami, FL, 7The Robert H. Lurie
(Dmin < 90% or Dmax > 110%), non-respect of required margins around Comprehensive Cancer Center of Northwestern University, Chicago,
the GTV, and a too high dose (V30 > 45%) received by the liver. Impact of IL, 8University of California, San Diego, CA, 9University of Utah
RTQAs on survival and toxicity will be presented at the meeting. Huntsman Cancer Hospital, Salt Lake City, UT, 10Washington
Conclusions: Quality assurance of complex radiation therapy was better University, St. Louis, MO
than in previous large studies but needs improvement. Its impact on
toxicity and outcome will be presented. Purpose/Objective(s): To generate a consensus RTOG atlas for CT and
Author Disclosure: F. Huguet: F. Honoraria; Roche. S. Racadot: None. D. for MR image-based cervical cancer brachytherapy by analyzing vari-
Goldstein: None. N. Spry: None. J. Van Laethem: None. P. Van Houtte: ability in contouring.
None. B. Glimelius: None. M. Gubanski: None. F. Bonnetain: None. P. Materials/Methods: RTOG Gynecologic Cancer Steering Committee
Hammel: F. Honoraria; Roche. G. Consultant; Roche. members received 3 cervical cancer cases to contour. Each case had
a 3T MRI at diagnosis, an MRI and a CT performed at the time of
brachytherapy within an hour of insertion, and clinical drawings
70 based on the MRI at diagnosis and at the time of brachytherapy.
Trends in the Utilization of Brachytherapy in Cervical Cancer in the Instructions mandated that CT contouring should be done first
United States without viewing the MRI at the time of brachytherapy. For CT
K. Han,1 M. Milosevic,1 A. Fyles,1 M. Pintilie,1 and A. Viswanathan2; contouring, physicians drew a CTV-cervix that included the cervix
Princess Margaret Hospital, Toronto, ON, Canada, 2Brigham and and any notable parametrial extension at the time of brachytherapy,
Women’s Hospital, Boston, MA but not the entire parametrial region if not involved. The cervix
contours started at the level of the applicator. MR contouring fol-
Purpose/Objective(s): To determine the trends in brachytherapy utiliza- lowed the GEC ESTRO guidelines for delineating an HR-CTV. The
tion in cervical cancer in the United States, and identify factors and clinical cases were then analyzed for consistency and clarity of target
survival benefit associated with brachytherapy treatment. delineation using an expectation maximization algorithm for simul-
Materials/Methods: Using the Surveillance, Epidemiology, and End taneous truth and performance level estimation (STAPLE), with
Results (SEER) database, 7,359 patients with stage IB2-IVA cervical kappa statistics as a measure of agreement between participants. The
cancer treated with external beam radiation therapy (EBRT) between conformity index (CI), defined as the ratio between the common
1988 and 2009 were identified. Logistic regression analysis was per- (mean) and encompassing (union) volume of a given pair of contours
formed on potential factors associated with brachytherapy use: age, was calculated for each of the six data sets. Dice coefficients were
marital status, race, ethnicity, metropolitan status, year of diagnosis, generated to compare CT and MR contours of the same case. The
SEER region, histology, grade, and stage. Propensity-score matching was Dice coefficient is the volume of the intersection divided by the
used to adjust for differences between patients who received brachy- average volume of the two structures.
therapy and those who did not from 2000 onwards (after the National Results: A total of 23 physicians contoured as part of this protocol.
Cancer Institute alert recommending concurrent chemotherapy). Cause- Results are shown in the Table. The mean tumor volume was smaller on
specific survival (CSS) and overall survival (OS) of matched patients MR than CT (p < 0.05 for all 3 cases). Kappa estimates showed
were estimated using the Kaplan-Meier method, and compared using the substantial agreement among physicians’ contours and were slightly
log-rank test. Multivariate survival analysis was performed using the Cox higher for CT. Sensitivity and specificity were similar between CT and
proportional hazard model. MR, indicating very little apparent difference in contours. Conformity
Results: Sixty-three percent of the 7,359 women received brachytherapy in index was slightly higher for CT compared to MR, indicating a higher
combination with EBRT and 37% received EBRT alone. The brachytherapy level of agreement on CT. Dice coefficients of the 95% consensus
utilization rate has decreased from 83% in 1988 to 58% in 2009 (p < .001), volumes comparing CT to MR were 59% for case 1, 71% for case 2 and
with a sharp decline of 23% in 2003 to 43%. Factors associated with higher 88% for case 3.
odds of brachytherapy use included younger age, married (versus single), Conclusions: MRI contoured volumes are consistently smaller than
earlier years of diagnosis, earlier stage and certain SEER regions. In the CT volumes. However, CT has a higher level of agreement that may
propensity-score matched cohort, brachytherapy treatment was associated be due to the more distinct contrast visible on the images at the time
with higher 5-year CSS (61.5% vs 48.7%, p < .001) and OS (54.8% vs 42.5%, of brachytherapy. A 95% consensus volume was generated for CT
p < .001). Brachytherapy treatment was independently associated with better and for MR and separate online atlases will be created based on these
CSS (HR 0.64; 95% CI, 0.57 to 0.71), and OS (HR 0.66; 95% CI, 0.60 to 0.74). results.
Conclusions: This population-based analysis reveals a concerning decline Author Disclosure: A.N. Viswanathan: None. B. Erickson: None.
in brachytherapy utilization, and significant geographic disparities in the S. Beriwal: None. D.P. D’Souza: None. E.L. Jones: None. L. Portelance:
delivery of brachytherapy in the U.S. Brachytherapy use is independently None. W. Small: None. C.M. Yashar: None. D.K. Gaffney: None. W.
associated with significantly higher CSS and OS, and should be imple- Bosch: None.
mented in all feasible cases.
Author Disclosure: K. Han: J. Funding Other; Fellowship salary support
from the Canadian Association of Radiation Oncology-Elekta research
fellowship and Canadian Institute of Health Research (CIHR) EIRR21
Oral Scientific Abstract 71; Table
award. M. Milosevic: None. A. Fyles: None. M. Pintilie: None. A. Vis-
wanathan: None. Structure Case 1 Case 1 Case 2 Case 2 Case 3 Case 3
Sensitivity 0.684 0.729 0.652 0.720 0.749 0.660
71 Specificity 0.977 0.978 0.998 0.985 0.983 0.996
Consensus Contours for CT Versus MRI in Image-Based Vol. Mean (cc) 33.70 16.20 55.16 39.77 59.36 44.54
Vol. Std. Dev. (cc) 10.10 6.26 16.10 11.93 15.45 15.54
Brachytherapy for Cervix Cancer to Generate an RTOG Atlas STAPLE Vol. (cc) 39.16 17.50 77.63 45.21 69.20 59.68
A.N. Viswanathan,1 B. Erickson,2 S. Beriwal,3 D.P. D’Souza,4 Kappa 0.65 0.64 0.71 0.67 0.70 0.66
E.L. Jones,5 L. Portelance,6 W. Small,7 C.M. Yashar,8 D.K. Gaffney,9