without metastatic disease, 22 underwent upfront surgery or radiotherapy followed by adjuvant concurrent chemo-radiotherapy (CCRT) or chemotherapy (the local first group); 7 underwent CCRT or chemotherapy before surgery(NAC group); 12 underwent surgery alone, and the remaining 10 underwent CCRT alone. Chemotherapy was administered to 53 (80%) patients. Among the 53 patients, 37 underwent chemo-regimen for small cell carcinoma (CDDP/CBDCA+VP16 or CPT11), whereas the remaining 16 patients underwent chemo-regimen for advanced cervical cancers (weekly CDDP, CDDP+5FU, DTX+CBDCA). The five-year overall survival for all patients was 52%. More specifically, the five-year overall survival by UICC stage I, II, IIIb, and IV was 64%, 76%, 57%, and 0%, respectively. No significant differences in survival were found by FIGO stage (I-IIa vs ! IIb) or by nodal status after excluding patients with UICC stage IV (pZ0.22 and pZ0.49, respectively). Despite the more advanced disease stage, patients in the NAC group tended to have better survival compared to those in the local first group (100% vs 63%; pZ0.12). The five-year survival rates in the small cell carcinoma chemo-regimen group and the advanced cervical cancer chemo-regimen group were 63% and 17%, respectively (P<0.01), and 80% and 33%, respectively (PZ0.07), when limited to CCRT patients. The same trend was observed regardless of UICC stages. Furthermore, no difference in five-year survival was observed between CDDP/CBDCA+VP16 and CDDP+CPT11. Conclusion: SCCC should be treated as localized small cell carcinoma. The application of chemotherapy before surgery may further improve patient survival.

defined as lack of failure within the 50% isodose line (ISL). Liver control is defined as lack of recurrence elsewhere within the liver, outside the 50% ISL. Results: Twenty-two patients with HCC were identified, and one patient was excluded due to not being treated with DTT-SBRT. Thus, 21 patients were analyzed. Median age at treatment was 74 (range 36 e 86). Median tumor size was 3.5 cm (range 1.3 e 6.5 cm), and median PTV volume was 119.4 cm 3. Baseline Child-Pugh Score (CPS) was A5/6 in 20 patients (95%), and B8 in 1 patient (5%). Median follow-up was 13.3 months (range 8.2 e 23.6). Actuarial local control was 100% at 1 year and at 2 years. Median time to failure elsewhere in the liver was 18.3 months. Liver control was 75% at 1 year, and 37% at 2 years. Overall survival was 91% at 2 years. In terms of acute toxicities within 3 months of DTT-SBRT, 18 patients (85.7%) did not have any changes in bilirubin or albumin. Grade 3 platelet toxicities occurred in 3/21 patients (14.3%). Three of 21 patients (14.3%) had an increase in CPS by 1 point from A5 to A6. One patient (4.8%) was treated as a bridge to transplant, and this individual had an increase in CPS by 2 points from B8 to B10. There were no grade 4 or 5 toxicities. Conclusion: DTT-SBRT using the VERO system resulted in PTV reduction and minimal acute toxicity, while achieving excellent local control. Most individuals failed elsewhere in the liver, emphasizing the need to spare as much normal liver as possible to allow further locoregional treatment options.

Liver-directed multi-modality treatment (LDMT) can provide substantial tumor control, which may allow cancer downstaging for conversion to curative surgery for the selected patients. In this study, we aimed to investigate the outcomes of liver-directed multi-modality therapy for locally advanced hepatocellular carcinoma (LAHCC) beyond the Milan criteria. Materials/Methods: We identified 1078 patients diagnosed with LAHCC who received LDMT between January 2001 and December 2018. We compared the outcomes based on no surgery, conversion to surgical resection, and liver transplantation (LT). Predictive factors for conversion to curative surgery were identified using logistic regression analysis. Results: The most frequently used LDMT strategies were concurrent chemoradiation (CCRT) (497 patients, 46.1%) followed by transarterial chemoembolization (TACE) plus radiotherapy (251 patients 23.3%), and TACE plus CCRT (233 patients, 21.6%). The median biologically effective radiation dose was 62.5 Gy (range, 40.4-150.0). After LDMT, 96 patients (8.9%) and 42 patients (3.9%) received surgical resection and LT, respectively. After a median follow-up of 14.4 months, the 5-year overall survival (OS) and progression-free survival (PFS) rate was 16.5% and 11.1% for all patients. Conversion to curative surgery significantly improved the 5-year OS (surgical resection vs. LT vs. no surgery: 58.1% vs. 54.3% vs. 10.2%, p<0.001) and PFS (42.0% vs. 22.5% vs. 6.3%, p<0.001). Patients aged <60 years with a single tumor, no treatment history, pre-treatment Child class A, lower pre-treatment tumor marker levels, and radiologic complete or partial response (all p<0.050) had a higher chance of conversion to surgery. Conclusion: LDMT could down-stage tumors to within the Milan criteria, allowing conversion to curative surgery and improving long-term survival for the selected patients. Clinicians must consider LDMT followed by curative surgery for young patients who are treatment-naïve and have good liver function with favorable tumor characteristics showing radiologic response to LDMT.

Purpose/Objective(s): We evaluated outcomes of palliative proton quadshot and stereotactic proton therapy to unresectable disease for patients with recurrent/metastatic sarcoma. Materials/Methods: From 2014 to 2018, 27 patients with recurrent or metastatic sarcomas were treated to 39 total sites with palliative proton RT with quad shot (14.8Gy/4 twice daily) or SBRT (27Gy/3 or 30Gy/ 5). Treatment for spine or brain metastases were not included. Follow up interval was defined as from the beginning of proton therapy. Analyzed factors included concurrent systemic therapy, Karnosfky performance status (KPS), initial treatment, presenting symptoms, and total radiation dose. Outcomes of interest included toxicity, ability to receive further systemic therapy, subjective palliative response and objective response using the RECIST criteria (stable, progressive, partial or complete response) as determined by two independent radiation oncologists. Results: Of the 39 total sites, 3 (7%) received SBRT and 36 (92%) received quad-shot with proton therapy. Of the 36 who received quadshot, 23 (64%) received 3 rounds. Median follow up was 8 months (IQR 4-13) for the entire cohort and 10 months (IQR 7-21) for living patients. Survival at 6 months was 70% and at 1 year was 52%. Median KPS was 90% at the time of first treatment. 89% (nZ24) of patients had soft tissue sarcomas with the most common histology being gastrointestinal stromal tumor (nZ7) while the remaining 3 patients had sarcomas arising from the bone. 25 (64%) sites were located in the abdomen or pelvis. 26 (67%) sites had been previously resected prior to recurrence and 5 (13%) sites had received prior RT. 17 (44%) treatments involved concurrent systemic therapy and 10 (37%) patients received further systemic therapy following proton therapy. Of the 17 sites treated with concurrent systemic therapy, 6 received chemotherapy, 10 received targeted therapy and 1 received both. Overall subjective palliative response was 77%. The most common presenting symptom was pain (87%, nZ34), which improved in 76% (nZ26) of cases. Of the 34 patients who had post-treatment imaging, overall objective response showing at least no change in size of the treated site was 79% (nZ27) with decrease in size of lesions observed in 26% (nZ9) of cases. 4 grade-3 acute toxicities were observed including abdominal infection, diarrhea, colonic obstruction and esophageal ulcer. None of these patients received concurrent systemic therapy. Conclusion: The proton quad-shot regimen and SBRT demonstrate favorable palliative response and toxicity profile. Even in the setting of gross disease, 37% of patients went on to receive further systemic therapy. This serves as a feasible alternative for patients with previously treated, recurrent or metastatic sarcomas where overall treatment options may be limited.

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