Patterns of care and outcomes of definitive external beam radiotherapy and radioembolization for localized hepatocellular carcinoma: A propensity score-adjusted analysis

329 Background: Hepatocellular carcinoma (HCC) is a leading cause of cancer mortality worldwide. Most patients with localized HCC are not surgically operable or transplantation candidates, thus there is an increasing role for nonsurgical locoregional therapies. Ablative external beam radiotherapy (XRT) and transarterial radioembolization (TARE) are two emerging radiotherapeutic treatments for localized HCC. However, there are little data comparing their efficacy. We therefore sought to evaluate their utilization and efficacy in a large nationwide cohort. Methods: We conducted an observational study of 2,685 patients from the National Cancer Database diagnosed with American Joint Committee on Cancer 7th edition clinical stage I-III HCC between 2004-2015, treated with definitive-intent XRT delivered in 1-15 fractions or TARE. The association between treatment modality (XRT versus TARE [referent]) and overall survival (OS) was defined using propensity score-weighted Kaplan-Meier estimators and propensity score-weighted multivariable Cox regressions. Results: Among 2,685 patients, 2,007 (74.7%) received TARE and 678 (25.3%) received XRT, with increasing usage for both from 2004-2015 ( Ptrend < 0.001), but with overall greater uptake and absolute usage of TARE. Patients who received TARE were more likely to have elevated alpha fetoprotein and more advanced stage ( P < 0.05 for all). Median OS was 14.5 months for the entire cohort. XRT was associated with an OS advantage compared to TARE on propensity score-unadjusted analysis (adjusted hazard ratio [AHR] 0.80, 95% CI 0.67-0.95, P = 0.013), but not on propensity score-adjusted analysis (AHR 0.93, 95% CI 0.76-1.14, P = 0.491). Conclusions: Our study demonstrates that while both XRT and TARE usage have increased with time, there was greater uptake and absolute use of TARE, especially in advanced disease. Nevertheless, we found no difference in survival between XRT and TARE after propensity score-adjustment. Given their equivalence on retrospective study, prospective trials are necessary

Pancreatic Ductal Adenocarcinoma

Objective: Patients who undergo an R0 resection of their pancreatic ductal adenocarcinoma (PDAC) have an improved survival compared with patients who undergo an R1 resection. It is unclear whether an R1 resection confers a survival benefit over locally advanced (LA) unresectable tumors. Our aim was to compare the survival of patients undergoing an R1 resection with those having LA tumors and to explore the prognostic significance of a 1-mm surgical margin. Methods: Clinicopathologic data from a pancreatic cancer database between January 1993 and July 2008 were reviewed. Locally advanced tumors had no evidence of metastatic disease at exploration. Results: A total of 1705 patients were evaluated for PDAC in the Department of Surgery. Of the 1084 (64%) patients who were surgically explored, 530 (49%) were considered unresectable (286 locally unresectable, 244 with distant metastasis). One hundred fifty-seven (28%) of the resected PDACs had an R1 resection. Patients undergoing an R1 resection had a slightly longer survival compared with those who had locally advanced unresectable cancers (14 vs 11 months; P < 0.001). Patients with R0 resections had a favorable survival compared with those with R1 resections (23 vs 14 months; P < 0.001), but survival after resections with 1-mm margin or less (R0-close) were similar to R1 resections: both groups had a significantly shorter median survival than patients with a margin of greater than 1 mm (R0-wide) (16 vs 14 vs 35 months, respectively; P < 0.001). Conclusions: Patients undergoing an R1 resection still have an improved survival compared with patients with locally advanced unresectable pancreatic adenocarcinoma. R0 resections have an improved survival compared with R1 resections, but this survival benefit is lost when the tumor is within 1 mm of the resection margin