International Journal of Radiation Oncology � Biology � PhysicsS134

tobacco/ alcohol use, marital and employment status) on PRO outcomes

was evaluated via stepwise regression using regular and logistic models.

Results: The median age was 65.0 years (range, 17-92); 724 (84%) male.

The mean (SD) weight was 186.3 � 42.8 lbs. One hundred twenty-one,

572, and 167 patients had early, locally advanced, and metastatic EC,

respectively. For this group of patients with early, locally advanced or

metastatic EC, the proportions with overall CDQOL were 12.1%, 28.0%

and 35.8%, respectively; after one year, they became 21.1%, 20.4% and

37.9%, respectively. The early and locally advanced EC patients had

similar QOL, while metastatic patients had worst QOL in 11 of 12 domains

(see Table). Compared to metastatic EC patients (intercept Z 7.05), the

mean (SE) parameter estimates in overall QOL gain were +0.88 (0.31) and

+0.22 (0.22) for early and locally advanced EC patients, respectively.

Smoking was a risk factor for overall CDQOL (current vs never, Odds

Ratio 2.42, 95% C.L., 1.33-4.41; past smoker vs never, OR 1.75, 95% C.L.,

1.14-2.69). Disease stage was a significant co-variate in all LASA scales

except for mental/intellectual and legal concerns.

Conclusions: The PRO-based tools produced evaluable QOL results,

whose deficit levels in turn correlated strongly to patient’s initial clinical

stage at presentation. Early and locally advanced EC patients had similar

QOL deficits, and the QOL of metastatic EC patients was worst. An early

intervention strategy targeting patients with marked CDQOL may enable

providers to better triage their clinical condition, assist in treatment

decision-making and communication, and consequently impact outcome.

Author Disclosure: T.T. Sio: None. H. Liu: None. B.F. Ginos: None. Y.

Romero: None. A. Jatoi: None. C. Deschamps: None. J.A. Sloan: None.

R.C. Miller: None.

Oral Scientific Abstract 330; Table Critical structure doses (repositioning/regular reoptimization/GM reoptimization)

Prostate case #1 Prostate case #2 Pancreas case

Rectum % vol at 70 Gy 28.7 / 17.3 / 13.7 15.2 / 6 / 4.8Rectum mean dose (Gy) 57.8 / 52.9 / 52.9 46.4 / 39.7 / 42.3Bladder % vol at 70 Gy 6.4 / 5 / 3.7 2.7 / 1.4 / 1.1Bladder mean dose (Gy) 25.1 / 22.8 / 21.1 16.6 / 15.8 / 15.2Mean duodenum (Gy) 22.4 / 18.8 / 21Duodenum D2% (Gy) 53.8 / 48 / 51.9Mean sm bowel (Gy) 9 / 8.3 / 7.8Mean lg bowel (Gy) 8.4 / 9 / 7.4

329Health-Related Quality of Life Outcomes Following DefinitiveTherapy Compared With Watchful Waiting in LocalizedAdenocarcinoma of the Prostate: An Analysis of the AtlantaVeterans Affairs Prostate DatabaseW.A. Hall,1,2 C. Nguyen,3 M. Goodman,3,2 J. Lipscomb,3,2

and T. Gillespie4,5; 1Emory University Department of Radiation Oncology,

Atlanta, GA, 2Winship Cancer Institute, Atlanta, GA, 3Rollins School of

Public Health, Atlanta, GA, 4Department of Surgical Oncology, Winship

Cancer Institute, Atlanta, GA, 5Veterans Affairs Medical Center (Atlanta),

Decatur, GA

Purpose/Objective(s): Adenocarcinoma of the prostate (ACP) manage-

ment options include external beam radiation therapy (EBRT), brachy-

therapy (BT), radical prostatectomy (RP), and watchful waiting (WW).

Few series have measured quality of life (QOL) outcomes including

reference patients undergoing WW or in predominately African American

(AA) men.

Materials/Methods: Data were extracted from the electronic medical

records (EMR) from the years 1996-2004. Patients included had newly-

diagnosed biopsy-confirmed, non-metastatic, clinical stage T1 and T2

ACP. Patients that received a combination of curative treatments (e.g. BT

and EBRT) were excluded from the study. Patient characteristics analyzed

included age, race, marital status, Charlson comorbidity index, psychiatric

comorbidity, PSA at diagnosis, Gleason score, core percentage involve-

ment, prostate volume, clinical stage, year of treatment, and pre-diagnosis

sexual, bowel, and urinary function. The outcomes of interest were

dichotomized variables scoring urinary, sexual, or bowel function based on

a standard toxicity grading scale. Data were abstracted by a single data

manager directly from the EMR before and after treatment. The WW

reference group included patients with biopsy proven ACP who continued

regular follow-up, but did not receive any definitive therapy.

Results: A total of 797 patients were eligible for inclusion in the study;

52.2% were African American (AA). Median follow-up was 24 months.

Radical prostatectomy was found to have greater deleterious impact on

urinary incontinence (odds ratio [OR] 39.62, 95% CI 15.02-104.48; p <

0.01) and sexual function (OR, 9.13, 95% CI 3.89-21.45, p < 0.01) than

patients choosing WW. Radiation therapy (RT) with EBRT also demon-

strated worsened urinary incontinence (OR 2.39, 95% CI 1.00-5.64, p Z

0.05), sexual function (OR 2.77, 95% CI 1.29-5.98, p < 0.01) and bowel

toxicity (OR 7.29, 95 % CI 3.4-15.64, p < 0.01), when compared with

WW. BT demonstrated worsened urinary incontinence (OR 4.31, 95% CI

1.6-11.64, p < 0.01), sexual function (OR 4.36, 95% CI 1.79-10.67, p <

0.01) and bowel toxicity (OR 5.43, 95% CI 2.19-13.49, p < 0.01)

compared with WW. Other factors related to worsened urinary inconti-

nence were psychiatric comorbidities and higher clinical stage. AA race

and younger age were associated with a larger magnitude of sexual decline

from baseline sexual function.

Conclusions: We have demonstrated a unique QOL analysis comparing

outcomes following intervention for localized ACP versus WW in a cohort

of predominately AA men. This data may help to guide treatment decisions

for previously under represented patients.

Author Disclosure: W.A. Hall: None. C. Nguyen: None. M. Goodman:

None. J. Lipscomb: None. T. Gillespie: None.

330A Fast Adaptive Replanning Method That Only Requires TargetDelineationE.E. Ahunbay, B.H. Kimura, and A.X. Li; Medical College of Wisconsin,

Milwaukee, WI

Purpose/Objective(s): Clinical use of online adaptive replanning has

been hampered by the impractically long time required to delineate

structures on the image of the day. We propose a new replanning algo-

rithm, named gradient maintenance (GM) algorithm, which only requires

delineation of the target, not full set of structures, drastically reducing

planning time.

Materials/Methods: The proposed GM algorithm was based on the

hypothesis that if the dose gradient toward each critical structure in

the adaptive plan can be maintained same as the original plan, the

intended plan quality of the original plan would be preserved. A

software tool was developed to rapidly and automatically generate

concentric ring structures around the target volume separately toward

each critical structure using the general directional/location relation-

ship of each structure to target from the original plan on the image of

the day. These ring structures were assigned appropriate dose

constraints determined from the dose distribution in the original plan,

to maintain the originally planned dose gradients. To quickly reach

these constraints (dose gradients) and the target dosimetry goals,

optimization of the adaptive plan starts from the original plan on the

image of the day. Plans generated based on image of the day by the

newly developed GM algorithm, the full-blown reoptimization using

the complete set of contours, and the standard IGRT repositioning for

representative cases including prostate and pancreas cases. For testing

purposes, no margin was used to account for inter-fractional

variations.

Results: Replanning using the new GM algorithm, requiring only the

target contour from the image of the day, can be completed within 5

minutes. Table below compares several dose-volume parameters generated

by the 3 scenarios. The results by the GM replanning were almost identical

to those from the full blown reoptimization with the complete set of

contours, and were improved from those generated by the standard IGRT

positioning. The target coverage (not in the table) was fully maintained for

Volume 87 � Number 2S � Supplement 2013 Oral Scientific Sessions S135

both GM and reoptimization plans, while IGRT repositioning led to

insufficient coverage for a prostate case.

Conclusions: The newly proposed gradient maintenance replanning algo-

rithm, increases planning speed for online adaptive RT. Plans generated by

GM algorithms are comparable to those generated by full-blown reop-

timization. The GM algorithm would especially suitable for sites with

small target surrounded by several critical structures, such as prostate and

pancreas.

Author Disclosure: E.E. Ahunbay: None. B.H. Kimura: None. A.X. Li:

None.

331Real-Time Assessment of Dosimetric Variations in Head-and-NeckRadiation TherapyX. Qi, J. Neylon, A. Santhanam, Y. Min, K. Sheng, D. Low, S. Lee,

M. Steinberg, and P. Kupelian; Department of Radiation Oncology, UCLA,

Los Angeles, CA

Purpose/Objective(s): To assess the cumulative dose delivered for head-

and-neck IMRT/IGRT treatment throughout the entire course.

Materials/Methods: Forty consecutive head and neck patients treated

with simultaneous integrated boost on a tomotherapy unit were

considered in this study. Treatment was performed using 2.0-2.1 Gy/fx

in 25-33 fractions. For every patient, a daily pre-treatment megavoltage

CT (MVCT) and a weekly long MVCT scan (covering the entire target

volume) were acquired. The targets and critical structures, such as

PTVs, spinal cord, parotid glands, were delineated on the planning CT.

A margin of 3 mm was used for the CTV-to-PTV expansion. A GPU-

based 3D image deformation/registration tool was developed and

employed for registering the weekly long MVCTs of each patient with

their corresponding planning CT. The deformation of each contoured

structures was computed to account for non-rigid change in the patient

setup. The Jacobian determinant for the PTVs and the critical structures

were used to quantify anatomical volume changes for each week. A

GPU based dose accumulation was performed to determine the deliv-

ered mean/minimum/maximum dose, equivalent uniform dose (EUD),

dose volume histograms (DVHs), as well as 3D gamma statistics

comparing the delivered dose to the plan.

Results: For a subgroup of 10 base-of-tongue/tongue/tonsil cases, cold

spots were observed in the cumulative dose distributions for the targets

compared to the plan. On average, the ratios (and the standard devi-

ations) between the delivered averaged minimum doses and the

planned dose, were 0.73 � 0.14, 0.66 � 0.28 and 0.78 � 0.19 for

PTV1 (the initial target volume), PTV2 (regions of involved nodes)

and PTV3 (elective nodal areas) respectively. The averaged maximum

doses were consistent with the planned maximum doses within 1.6%,

while the cumulative mean dose ratios were within 5% and 3% of the

planned mean doses for all PTVs and CTVs respectively. The cumu-

lative cord maximum and mean doses were 23% and 10% higher than

the planned doses; at least one parotid gland received more than the

planned mean doses by 4%. During the treatment course, we observed

the target volume and weight change by 20% and 13.3%, respectively,

which resulted in larger cumulative EUD variations of up to 11, 22

and 8% for PTV1-3, respectively. The percentage volume that failed to

meet the gamma criteria of 1%/1 mm for PTVs were 28.2 � 11.0,

32.6 � 18.8, and 29.7 � 13.9, respectively. The tool achieved a run-

time of 30 sec for registering one MVCT with a planning CT, 0.1 sec

for the forward dose accumulation and 10 sec for the 3D gamma

statistical analyses.

Conclusions: Cumulative dose variations were documented using

a GPU-based image framework to compare with planned doses. The

framework enables real-time dose verification and possible re-

planning.

Author Disclosure: X. Qi: None. J. Neylon: None. A. Santhanam: None. Y.

Min: None. K. Sheng: None. D. Low: None. S. Lee: None. M. Steinberg:

None. P. Kupelian: E. Research Grant; Varian Medical Systems, Inc. F.

Honoraria; Accuray Inc., Siemens Medical Solutions, Viewray Inc.

332Prospective Pilot Study Assessing the Need for Adaptive RadiationTherapy in Unresected Bulky Disease and in Postoperative Head-and-Neck Cancer PatientsO.M. Mahmoud,1,2 I.M. Reis,3 M.A. Samuels,1 N. Elsayyad,1 J.A. Both,1

E. Bossart,1 E. ElGhoneimy,2 M. Moustafa,2 M. AbdAllah,2

and C. Takita1; 1Radiation Oncology Department, Sylvester

Comprehensive Cancer Center, University of Miami, Miami, FL, 2Kasr El-

Aini Center of Radiation Oncology and Nuclear Medicine (NEMROCK),

Cairo Faculty of Medicine, Cairo, Egypt, 3Biostatistics core, Sylvester

Comprehensive Cancer Center, University of Miami, Miami, FL

Purpose/Objective(s): The use of Adaptive radiation therapy (ART) in

head and neck cancer (HNC) is evolving. We attempted to quantify

anatomic volumetric changes during IMRT in two groups of patients; those

with bulky disease (Group B) and those treated postoperatively (Group

PO). Feedback CT imaging at 3 and 6 weeks was used to assess the

comparative magnitude of anatomical variation caused by tumor shrinkage

or weight loss in the individual patient and to trigger plan alteration.

Materials/Methods: Twenty-two stage III/IV patients with HNC treated

with IMRT and chemotherapy were studied; 11 in Group B (tumor > 4 cm)

and 11 in Group PO. Planning CT images at Weeks 3 and 6 were fused

with the initial CT-based plan (Week 0). Volumes measured were: high risk

CTV (CTV HR), low risk CTV (CTV LR), right parotid (RP), left parotid

(LP) and spinal cord (SC). An event to trigger ART was defined as: SC

maximum dose > 45 Gy, RP or LP mean dose > 26 Gy, or CTV coverage

< 95%. Percentage changes in each of these volumes relative to baseline

were analyzed with a two-way repeated-measures ANOVA model using

SAS Mixed procedure where Groups (B or PO) were considered as ‘fixed

factor’ and time (Week 3 or 6) as ‘repeated measures factor’. Fisher’s exact

test was used for group comparisons with respect to categorical outcomes.

Results: For Group B, the means of % volume reduction at Weeks 3 and 6

respectively were: 7.2% and 12.8% (p Z 0.043) for CTV HR, 4.1% and

7.9% (p Z 0.058) for CTV LR, 19% and 30.9% (p < 0.001) for RP and

18.2% and 30.1% (p < 0.0001) for LP. For Group PO, the corresponding

means of % volume reduction were not statistically significant at Weeks 3

and 6 for CTV HR (7.8% and 10.9%, respectively) and CTV LR (6.4% and

6.4%, respectively) but statistically significant for RP (16.6 % and 25.3%,

p Z 0.005) and LP (10% and 23.1%, p < 0.0001). The proportion of

patients with � 1 event triggering ART was higher in Group B vs Group

PO: 72.7% and 18.2% (pZ 0.03) overall, 54.6% and 1.8%, (pZ 0.064) at

Week 3 (63.6% vs 18.2%, (pZ 0.081) at Week 6. In group B, 8/11 patients

had the following triggering events: overdose in SC (n Z 2), RP (n Z 3)

and LP (nZ 5), or < 95% coverage in CTV HR (nZ 3) or CTV LR (nZ5). Such events occurred in 2/11 in Group PO: SC overdose (n Z 1) and

CTV LR under-dose (n Z 1). Percentage weight reduction was 4.9% vs

8.6% (p < 0.001) for Group B and 2.8% vs 4.7% (p Z 0.043) for Group

PO at Week 3 and 6, respectively. The difference in weight loss between

the 2 groups approached significance (p Z 0.053) at week 6.

Conclusions: Our study highlights the value for ART in HNC with bulky

disease. In contrast, based on these data, the benefit of ART in PO patients

is less clear. The study results infer that the magnitude of change in ART-

relevant volumes appears to be related more to tumor response and

reduction in parotid size rather than to weight loss.

Author Disclosure: O.M. Mahmoud: None. I.M. Reis: None. M.A.

Samuels: None. N. Elsayyad: None. J.A. Both: None. E. Bossart: None. E.

ElGhoneimy: None. M. Moustafa: None. M. AbdAllah: None. C. Takita:

None.

333Automatic Planning of Head and Neck Treatment Plans: A Way toOptimize the Plan Quality and Reduce WorkloadI. Hazell,1 K. Bzdusek,2 P. Kumar,3 C.R. Hansen,1 A. Bertelsen,1

and C. Brink1,4; 1Laboratory of Radiation Physics, Odense University

Hospital, Odense, Denmark, 2Philips Healthcare, Fitzburg, WI, 3Philips

Electronics India Ltd., Bangalore, India, 4Institute of Clinical Research,

University of Southern Denmark, Odense, Denmark