title: Influence of noncompliance with radiation therapy protocol guidelines and operative bed recurrences for children with rhabdomyosarcoma and microscopic residual disease: a report from the Children's Oncology Group.
abstract: OBJECTIVE
  Postoperative radiation therapy (RT) is recommended for patients with rhabdomyosarcoma having microscopic disease. Sometimes RT dose/volume is reduced or omitted in an attempt to avoid late effects, particularly in young children. We reviewed operative bed recurrences to determine if noncompliance with RT protocol guidelines influenced local-regional control.
  
  
  METHODS
  All operative bed recurrences among 695 Group II rhabdomyosarcoma patients in Intergroup Rhabdomyosarcoma Study Group (IRS) I through IV were reviewed for deviation from RT protocol. Major/minor dose deviation was defined as >10% or 6-10% of the prescribed dose (40-60 Gy), respectively. Major/minor volume deviation was defined as tumor excluded from the RT field or treatment volume not covered by the specified margin (preoperative tumor volume and 2- to 5-cm margin), respectively. No RT was a major deviation.
  
  
  RESULTS
  Forty-six of 83 (55%) patients with operative bed recurrences did not receive the intended RT (39 major and 7 minor deviations). RT omission was the most frequent RT protocol deviation (19/46, 41%), followed by dose (17/46, 37%), volume (9/46, 20%), and dose and volume deviation (1/46, 2%). Only 7 operative bed recurrences occurred in IRS IV (5% local-regional failure) with only 3 RT protocol deviations. Sixty-three (76%) patients with recurrence died of disease despite retrieval therapy, including 13 of 19 nonirradiated children.
  
  
  CONCLUSIONS
  Over half of the operative bed recurrences were associated with noncompliance; omission of RT was the most common protocol deviation. Three fourths of children die when local-regional disease is not controlled, emphasizing the importance of RT in Group II rhabdomyosarcoma.
authors.affiliation: Department of Radiation Oncology, University of Utah Health Sciences and Huntsman Cancer Institute, Salt Lake City, UT, USA. lynn.million@hci.utah.edu
authors.forename: Lynn
authors.initials: L
authors.lastname: Million
authors.forename: James
authors.initials: J
authors.lastname: Anderson
authors.forename: John
authors.initials: J
authors.lastname: Breneman
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Hawkins
authors.forename: Fran
authors.initials: F
authors.lastname: Laurie
authors.forename: Jeff
authors.initials: J
authors.lastname: Michalski
authors.forename: David
authors.initials: D
authors.lastname: Rodeberg
authors.forename: Moody
authors.initials: M
authors.lastname: Wharam
authors.forename: Suzanne
authors.initials: S
authors.lastname: Wolden
authors.forename: Sarah S
authors.initials: SS
authors.lastname: Donaldson
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000532:radiotherapy*; D018365:Neoplasm, Residual; D011879:Radiotherapy Dosage; D018232:Rhabdomyosarcoma, Alveolar / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D018233:Rhabdomyosarcoma, Embryonal / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D047368:Tumor Burden