Outcomes and Predictors of Toxicity after Selective Internal Radiation Therapy Using Yttrium-90 Resin Microspheres for Unresectable Hepatocellular Carcinoma

Purpose

We sought to report outcomes and toxicity in patients with hepatocellular carcinoma (HCC) who received resin yttrium-90 selective internal radiation therapy (⁹⁰Y-SIRT) and to identify factors associated with declining liver function.

Methods

Patients treated with ⁹⁰Y-SIRT were retrospectively evaluated. Radiographic response was assessed using RECIST 1.1. Median liver progression-free survival (LPFS) and overall survival (OS) were calculated using the Kaplan–Meier method. Bivariate analysis was used to examine associations between change in Child-Pugh (CP) score/class and patient characteristics and treatment parameters.

Results

Twenty-seven patients with unresectable HCC underwent SIRT, 52% were CP Class A, 48% were Class B, 11% were BCLC stage B, and 89% were stage C. Forty-four percent of patients had portal vein thrombus at baseline. One-third of patients received bilobar treatment. Median activity was 32.1 mCi (range 9.18–43.25) and median-­absorbed dose to the liver was 39.6 Gy (range 13.54–67.70). Median LPFS and OS were 2.5 and 11.7 months, respectively. Three-month disease control rate was 63 and 52% in the target lesions and whole liver, respectively. New onset or worsened from baseline clinical toxicities were confined to Grade 1–2 events. However, new or worsened Grade 3–4 laboratory toxicities occurred in 38% of patients at 3 months and 43% of patients at 6 months following SIRT (six had lymphocytopenia, three had hypoalbuminemia, and two had transaminasemia). After 3 months, six patients had worsened in CP score and five had worsened in class from baseline. After 6 months, four patients had worsened in CP score and one had worsened in class from baseline. Pretreatment bilirubinemia was associated with a 2+ increase in CP score within 3 months (P = 0.001) and 6 months (P = 0.039) of ⁹⁰Y-SIRT. Pretreatment transaminasemia and bilirubinemia were associated with increased CP class within 3 months of SIRT (P = 0.021 and 0.009, respectively).

Conclusion

⁹⁰Y-SIRT was well-tolerated in patients with unresectable HCC, with no Grade 3–4 clinical toxicities. However, Grade 3–4 laboratory toxicities and worsened CP scores were more frequent. HCC patients with pretreatment bilirubinemia or transaminasemia may be at higher risk of experiencing a decline in liver function following ⁹⁰Y-SIRT.

Five-fraction stereotactic radiosurgery (SRS) for single inoperable high-risk non-small cell lung cancer (NSCLC) brain metastases

BACKGROUND

Achieving durable local control while limiting normal tissue toxicity with definitive radiation therapy in the management of high-risk brain metastases remains a radiobiological challenge. The objective of this study was to examine the local control and toxicity of a 5-fraction stereotactic radiosurgical approach for treatment of patients with inoperable single high-risk NSCLC brain metastases.

METHODS

This retrospective analysis examines 20 patients who were deemed to have "high-risk" brain metastases. High-risk tumors were defined as those with a maximum diameter greater than 2 cm and/or those located within an eloquent cortex. Patients were evaluated by a neurosurgeon prior to treatment and determined to be inoperable due to tumor or patient characteristics. Patients were treated using the CyberKnife® SRS system in 5 fractions to a total dose of 30 Gy, 35 Gy, or 40 Gy.

RESULTS

Twenty patients with a median age of 65.5 years were treated from April 2010 to August 2014 in 5 fractions to a median total dose of 35 Gy. At a median follow up of 11.3 months local tumor control was observed in 18 of 20 metastases (90 %). Both local failures were observed in patients receiving a lower dose of 30 Gy. Median pre-treatment dexamethasone dose was 10 mg/day and median post-treatment nadir dose was 0 mg/day. Salvage intracranial therapy was required in 45 % of patients. Symptomatic radionecrosis was observed in 4 of 20 patients (20 %), two of which were treated to 40 Gy and the remainder to 35 Gy. Kaplan-Meier 1-year, 2-year, and median survival were calculated to be 45 %, 20 %, and 13.2 months, respectively.

CONCLUSIONS

Five-fraction SRS to a total dose of 35 Gy appears to be a safe and effective management strategy for single high-risk NSCLC brain metastases, while a total dose of 40 Gy leads to an excess risk of neurotoxicity.

Four-dimensional computed tomography prediction of inter- and intrafractional upper gastrointestinal tumor motion during fractionated stereotactic body radiation therapy

PURPOSE

Respiratory-induced tumor motion of upper gastrointestinal (GI) tumors during radiation therapy is often assessed using a single 4-dimensional computed tomography (4D-CT) and presumed to be representative during fractionated treatment regimens. The purpose of this study was to examine the intra- and interfraction correlations of tumor motion between pretreatment 4D-CT and real-time fiducial-based motion tracking in patients treated with fractionated stereotactic body radiation therapy (SBRT) for upper GI malignancies.

METHODS AND MATERIALS

Fourteen patients with upper GI tumors underwent fractionated SBRT using the CyberKnife radiosurgical system with Synchrony respiratory motion management. Before treatment, each patient underwent a free-breathing 4D-CT scan and fiducial motion was tracked for each phase of the respiratory cycle. Real-time fiducial positions recorded during delivery of each SBRT fraction were extracted from the CyberKnife planning system. Displacements were compared between those predicted by 4D-CT and those recorded by Synchrony during treatment in the left-right (LR), anteroposterior (AP), and superoinferior (SI) directions.

RESULTS

The 4D-CT scans demonstrated little correlation with real-time mean fiducial displacement as determined by Pearson correlation with coefficients of 0.45, 0.52, and 0.63 in the SI, AP, and LR directions, respectively. Cohort-averaged maximum fiducial displacements based on 4D-CT and real-time tracking were measured to be 3.86 ± 1.40 mm versus 10.73 ± 7.03 mm, 2.29 ± 1.02 mm versus 4.44 ± 3.33 mm, and 1.45 ± 0.49 mm versus 2.67 ± 2.49 mm in the SI, AP, and LR directions, respectively. Mean fiducial displacements were greater than that predicted by the maximum displacements on the corresponding 4D-CT scan in 39%, 22%, and 25% of SBRT fractions in the SI, AP, and LR directions, respectively.

CONCLUSIONS

Comparison of 4D-CT with real-time fiducial tracking demonstrated significant inter- and intrafractional discrepancies, particularly in the SI direction, which could result in compromise of target coverage when planning with a single free-breathing 4D-CT.

Mechanisms of the induction of apoptosis mediated by radiation-induced cytokine release

The aim of the present work was to investigate the mechanisms of radiation-induced bystander signalling leading to apoptosis in non-irradiated co-cultured cells. Cultured non-transformed cells were irradiated, and the effect on the apoptosis rate on co-cultured non-irradiated malignant cells was determined. For this, two different levels of the investigation are presented, i.e. release of signalling proteins and transcriptomic profiling of the irradiated and non-irradiated co-cultured cells. Concerning the signalling proteins, in this study, the attention was focussed on the release of the active and latent forms of the transforming growth factor-β1 protein. Moreover, global gene expression profiles of non-transformed and transformed cells in untreated co-cultures were compared with those of 0.5-Gy-irradiated non-transformed cells co-cultured with the transformed cells. The results show an effect of radiation on the release of signalling proteins in the medium, although no significant differences in release rates were detectable when varying the doses in the range from 0.25 to 1 Gy. Moreover, gene expression results suggest an effect of radiation on both cell populations, pointing out specific signalling pathways that might be involved in the enhanced induction of apoptosis.

Chromatographische Fraktionierung und Trennung von Polystyrolen an Silicagel

Silica gel as a filler of separation columns fractionates and separates dissolved polystyrenes. Fractionation means: Continuous distribution of the polymeric homologues among the successive fractions of the eluate. Separation means: Discontinuous distribution. In both cases the polymeric homologues with higher molecular weights are transported more rapidly through the columns than the polymeric homologues with lower molecular weigths. Fractionation and separation of polystyrenes are based on characteristics of the space system within the silica gel particles. With equal dimensions of the columns fractionation and separation grow with the pore size of the silica gel particles.

Treatment of metastatic colorectal cancer with cetuximab: influence on the quality of life

BACKGROUND

Epidermal Growth Factor Receptor (EGFR) antibodies are innovative anti-cancer drugs prolonging survival in metastatic colocrectal cancer. However, due to adverse drug reactions, patients develop acneform skin toxicities. We hypothesized that the skin reaction leads to a decline in general (QOL) and dermatological health related quality of life (HQOL). Furthermore, we aimed at evaluating predictors for QOL and HQOL to improve individual adjustment of therapy.

METHODS

40 outpatients with metastatic colocrectal cancer were involved in this study. According to their KRAS status, patients were allocated to 2 groups: The CTCX group (n = 20; KRAS wild-type) was treated with the EGFR-antibody Cetuximab plus chemotherapy, the CT group (n = 20; KRAS mutation) was receiving chemotherapy only. Psychological assessment consisted of questionaires to evaluate QOL and HQOL, depression, coping-styles, health beliefs and the patient´s personality.

RESULTS

Between the two groups, no significanct difference in QOL was found, QOL remained stable over the course of treatment. Yet, the severity of the skin reactions had a significant influence on HQOL. Internal health beliefs and high compliance were found to be protective factors, while passive coping strategies, depression and the personality trait neuroticism were identified as risk factors.

DISCUSSION

Interdisciplinary cooperation between medical professionals and psycho-oncologists is strongly recommended to encourage patients to embark on and to retain EGFR-antibody therapy. If risk factors are present, psycho-oncological therapy should focus on the minimization of depression and on the development of active coping strategies.

Abstract 1860: Metabolomics for the identification of prognostic biomarkers of pancreatic cancer

Introduction: Although the survival outcomes of Pancreatic Ductal Adenocarcinoma (PDAC) continue to be poor, clinical and basic research in this field is disproportionately under-represented as compared to other cancer sites. Currently, there is no blood or fluid test for diagnosis or prognosis of PDAC. Sensitive and specific biomarkers are thus critical for improving clinical outcomes of PDAC. Our goal in this study was to identify molecular features that could be used for disease stratification. The underlying hypothesis was that targeted, quantitative evaluation of molecular fingerprints of PDAC in serum, calculated originally via matched tissue metabolomic profiles using an untargeted approach may have direct clinical applicability.

Approach: We have used mass spectrometry based metabolomics, an emerging field that provides new information on biological perturbations based on changes in multiple endogenous metabolites. These metabolites represent the endpoint of cellular processes and are hence a direct readout of the phenotype or the physiological status. Detection of PDAC using a metabolomics approach is based on the establishment of specific key metabolite signatures in pancreatic tumor tissue derived from patients diagnosed with PDAC. A shortlisted panel of these putative markers was tested for their pre-clinical performance using serum samples from the same patients. This combinatorial approach allowed us to interrogate the PDAC tissue metabolome in a global and unbiased fashion and subsequently test the clinical applicability using a targeted approach in serum samples.

Results: The untargeted metabolomics profiling resulted in the identification of a panel of key metabolites which could help discriminate PDAC tissue profiles from pancreatitis and colo-rectal tumor tissue. Validation of these metabolites in serum is ongoing.

Conclusion: Our results demonstrate the power of metabolomics for developing clinical assays for diagnosis and prognosis of PDAC. Identification of cellular target molecules, associated with pancreas cancer oncogenesis, progression and metastasis is critical for designing new treatment options for advanced stage disease. Developing a specific and sensitive panel of bio-markers offers a pragmatic approach towards increasing overall survival rates; identify molecular targets for therapeutic development, improving treatment strategies and thus clinical outcomes

Supported by American Cancer Society

Citation Format: Keith Unger, Prabhjit Kaur, Amrita K. Cheema. Metabolomics for the identification of prognostic biomarkers of pancreatic cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1860. doi:10.1158/1538-7445.AM2013-1860

Malignant melanoma and radiotherapy: past myths, excellent local control in 146 studied lesions at Georgetown University, and improving future management

Introduction: Once thought to be radioresistant, emerging cellular and clinical evidence now suggests melanoma can respond to large radiation doses per fraction. Materials and Methods: We conducted a retrospective study of all patients treated with stereotactic radiosurgery and stereotactic body radiotherapy at Georgetown University Hospital from May 2002 through November 2008 and studied the classic extrapolated total dose corrected for volume (ETD_vol) model for predicting melanoma tumor response. Region-specific tumor outcomes were categorized by RECIST criteria and local control curves were estimated and analyzed when stratified by ETD_vol thresholds by use of the Kaplan–Meier method. Results: Follow-up information was available for 78 lesions (49 intracranial, 8 spinal, and 21 body) with mean follow-up period of 9.2 (range, 2–36) months. 1-year local control rates for intracranial, spinal, and body tumors were 84, 100, and 72%, respectively. Treatments in general were well-tolerated. Increased ETD_vol (p < 0.001) among intracranial sites resulted from larger (p < 0.001) doses per fraction combined with smaller (p < 0.001) tumor diameters. Intracranial 6-, 12-, and 24-month local control rates when treated above ETD_vol threshold of 230 Gy were all 90 vs. 89, 80, and 53% below this threshold. Body 6- and 12-month local control rates when treated above ETD_vol threshold of 100 Gy were 100 and 80% vs. 74 and 59% below this threshold. Discussion: By tailoring to melanoma’s unique radiobiology with large radiation doses per fraction, favorable local control was safely achieved. The ETD_vol model combines the important factor of dose per fraction in melanoma treatment with a volume correction factor to predict tumor response. Although limited sample size may have prevented reaching statistical significance for local control improvements using ETD_vol thresholds, optimal thresholds may exist to improve future tumor responses and further research is required.

Scoring system predictive of survival for patients undergoing stereotactic body radiation therapy for liver tumors

Background

Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumors. This study evaluated outcomes after SBRT to identify prognostic variables and to develop a novel scoring system predictive of survival.

Methods

The medical records of 52 patients with a total of 85 liver lesions treated with SBRT from 2003 to 2010 were retrospectively reviewed. Twenty-four patients had 1 lesion; 27 had 2 or more. Thirteen lesions were primary tumors; 72 were metastases. Fiducials were placed in all patients prior to SBRT. The median prescribed dose was 30 Gy (range, 16 – 50 Gy) in a median of 3 fractions (range, 1–5).

Results

With median follow-up of 11.3 months, median overall survival (OS) was 12.5 months, and 1 year OS was 50.8%. In 42 patients with radiographic follow up, 1 year local control was 74.8%. On univariate analysis, number of lesions (p = 0.0243) and active extralesional disease (p < 0.0001) were predictive of OS; Karnofsky Performance Status (KPS) approached statistical significance (p = 0.0606). A scoring system for predicting survival was developed by allocating 1 point for each of the three following factors: active extralesional disease, 2 or more lesions, and KPS ≤ 80%. Score was associated with OS (p < 0.0001). For scores of 0, 1, 2 and 3, median survival intervals were 34, 12.5, 7.6, and 2.8 months, respectively.

Conclusions

SBRT offers a safe and feasible treatment option for liver tumors. A prognostic scoring system based on the number of liver lesions, activity of extralesional disease, and KPS predicts survival following SBRT and can be used as a guide for prospective validation and ultimately for treatment decision-making.

Stereotactic body radiation therapy for reirradiation of localized adenocarcinoma of the pancreas

BACKGROUND

Local control rates are poor in the treatment of pancreatic cancer. We investigated the role of hypofractionated stereotactic body radiation therapy (SBRT) for salvage or boost treatment after conventional doses of external beam radiation therapy.

METHODS

All patients treated with SBRT for pancreatic adenocarcinoma at Georgetown University from June 2002 through July 2007 were examined. Eligible patients had prior external beam radiation therapy to the pancreas. Treatment parameters and clinical and radiographic follow-up were evaluated.

RESULTS

Twenty-eight patients were identified who received SBRT after a median prior external beam radiotherapy dose of 50.4 Gy. The median patient age was 63 years old and the median follow-up was 5.9 months. Twelve of fourteen (85.7%) evaluable patients were free from local progression, with three partial responses and nine patients with stable disease. Toxicity consisted of one case of acute Grade II nausea/vomiting, and two cases of Grade III late GI toxicity. The median overall survival was 5.9 months, with 18% survival and 70% freedom from local progression at one year.

CONCLUSIONS

Hypofractionated SBRT reirradiation of localized pancreatic cancer is a well-tolerated treatment. Most patients are free from local progression, albeit with limited follow-up, but overall survival remains poor.

Fiducial-free CyberKnife stereotactic body radiation therapy (SBRT) for single vertebral body metastases: acceptable local control and normal tissue tolerance with 5 fraction approach

This retrospective analysis examines the local control and toxicity of five-fraction fiducial-free CyberKnife stereotactic body radiation therapy (SBRT) for single vertebral body (VB) metastases. All patients had favorable performance status (ECOG 0-1), oligometastatic disease, and no prior spine irradiation. A prescribed dose of 30-35 Gy was delivered in five fractions to the planning target volume (PTV) using the CyberKnife with X-sight spine tracking. Suggested maximum spinal cord and esophagus point doses were 30 and 40 Gy, respectively. A median 30 Gy (IQR, 30-35 Gy) dose was delivered to a median prescription isodose line of 70% (IQR, 65-77%) to 20 patients. At 34 months median follow-up (IQR, 25-40 months) for surviving patients, the 1- and 2-year Kaplan-Meier local control estimates were 80 and 73%, respectively. Two of the five local failures were infield in patients who had received irradiation to the gross tumor volume and three were paravertebral failures just outside the PTV in patients with prior corpectomy. No local failures occurred in patients who completed VB radiation alone. The 1- and 2-year Kaplan-Meier overall survival estimates were 80 and 57%, respectively. Most deaths were attributed to metastatic disease; one death was attributed to local recurrence. The mean maximum point doses were 26.4 Gy (SD, 5.1 Gy) to the spinal cord and 29.1 Gy (SD, 8.9 Gy) to the esophagus. Patients receiving maximum esophagus point doses greater than 35 Gy experienced acute dysphagia (Grade I/II). No spinal cord toxicity was documented. Five-fraction fiducial-free CyberKnife SBRT is an acceptable treatment option for newly diagnosed VB metastases with promising local control rates and minimal toxicity despite the close proximity of such tumors to the spinal cord and esophagus. A prospective study aimed at further enhancing local control by targeting the intact VB and escalating the total dose is planned.

Stereotactic body radiation therapy for liver metastases from colorectal cancer: analysis of safety, feasibility, and early outcomes

INTRODUCTION

Colorectal cancer (CRC) is the third leading cause of cancer-related death in the U.S. Many patients with CRC develop hepatic metastases as the sole site of metastases. Historical treatment options were limited to resection or conventional radiation therapy. Stereotactic body radiation therapy (SBRT) has emerged as a rational treatment approach. This study reviews our experience with SBRT for patients with liver metastases from CRC.

MATERIALS AND METHODS

Fourteen histologically confirmed hepatic CRC metastases in 11 consecutive patients were identified between November, 2004 and June, 2009 at Georgetown University. All patients underwent CT-based treatment planning; a few also had MRI or PET/CT. All patients had fiducial markers placed under CT guidance and were treated using the CyberKnife system. Treatment response and toxicities were examined; survival and local control were evaluated.

RESULTS

Most patients were treated to a single hepatic lesion (n = 8), with a few treated to two lesions (n = 3). Median treatment volume was 99.7 cm(3), and lesions were treated to a median BED(10) of 49.7 Gy (range: 28-100.8 Gy). Median follow-up was 21 months; median survival was 16.1 months, with 2 year actuarial survival of 25.7%. One year local control was 72%. Among patients with post-treatment imaging, eight had stable disease (80%) and two had progressive disease (20%) at first follow-up. The most common grade 1-2 acute toxicities included nausea and alterations in liver function tests; there was one grade 3 toxicity (elevated bilirubin), and no grade 4-5 toxicities.

DISCUSSION

SBRT is safe and feasible for the treatment of limited hepatic metastases from CRC. Our results compare favorably with outcomes from previous studies of SBRT. Further studies are needed to better define patient eligibility, study the role of combined modality treatment, optimize treatment parameters, and characterize quality of life after treatment.

Integrating research on thyroid cancer after Chernobyl--the Chernobyl Tissue Bank

The only unequivocal radiological effect of the Chernobyl accident on human health is the increase in thyroid cancer in those exposed in childhood or early adolescence. In response to the scientific interest in studying the molecular biology of thyroid cancer after Chernobyl, the Chernobyl Tissue Bank was established. The project is supported by the governments of Ukraine and Russia, and financially supported (in total around US$3 million) by the European Commission, the National Cancer Institute of the USA and the Sasakawa Memorial Health Foundation of Japan. The project began collecting a variety of biological samples from patients on 1 October 1988, and has supplied material to 21 research projects in Japan, the USA and Europe. The establishment of the Chernobyl Tissue Bank has facilitated co-operation between these research projects and the combination of clinical and research data provides a paradigm for cancer research in the molecular biological age.

CyberKnife for hilar lung tumors: report of clinical response and toxicity

Objective

To report clinical efficacy and toxicity of fractionated CyberKnife radiosurgery for the treatment of hilar lung tumors.

Methods

Patients presenting with primary and metastatic hilar lung tumors, treated using the CyberKnife system with Synchrony fiducial tracking technology, were retrospectively reviewed. Hilar location was defined as abutting or invading a mainstem bronchus. Fiducial markers were implanted by conventional bronchoscopy within or adjacent to tumors to serve as targeting references. A prescribed dose of 30 to 40 Gy to the gross tumor volume (GTV) was delivered in 5 fractions. Clinical examination and PET/CT imaging were performed at 3 to 6-month follow-up intervals.

Results

Twenty patients were accrued over a 4 year period. Three had primary hilar lung tumors and 17 had hilar lung metastases. The median GTV was 73 cc (range 23-324 cc). The median dose to the GTV was 35 Gy (range, 30 - 40 Gy), delivered in 5 fractions over 5 to 8 days (median, 6 days). The resulting mean maximum point doses delivered to the esophagus and mainstem bronchus were 25 Gy (range, 11 - 39 Gy) and 42 Gy (range, 30 - 49 Gy), respectively. Of the 17 evaluable patients with 3 - 6 month follow-up, 4 patients had a partial response and 13 patients had stable disease. AAT t a median follow-up of 10 months, the 1-year Kaplan-Meier local control and overall survival estimates were 63% and 54%, respectively. Toxicities included one patient experiencing grade II radiation esophagitis and one patient experiencing grade III radiation pneumonitis. One patient with gross endobronchial tumor within the mainstem bronchus developed a bronchial fistula and died after receiving a maximum bronchus dose of 49 Gy.

Conclusion

CyberKnife radiosurgery is an effective palliative treatment option for hilar lung tumors, but local control is poor at one year. Maximum point doses to critical structures may be used as a guide for limiting toxicities. Preliminary results suggest that dose escalation alone is unlikely to enhance the therapeutic ratio of hilar lung tumors and novel approaches, such as further defining the patient population or employing the use of radiation sensitizers, should be investigated.

[Chronic osteitis of the lower extremities. An interdisciplinary treatment concept]

INTRODUCTION

The purpose of this investigation was the retrospective analysis of patients with delayed infections, chronic posttraumatic osteitis of the lower extremities and free-flap coverage after radical debridement of bone and soft tissue.

METHODS

From the time period 1994-2003 a total of 22 patients including 4 females and 18 males were investigated. In 16 patients treatment was carried out on the lower leg and in 6 patients the foot was treated with subsequent free-flap coverage. In 14 cases the latissimus dorsi muscle was used, in 5 cases the gracilis muscle, in 2 cases parascapula flaps were used and in 1 case the serratus anterior muscle. The average age of the patients was 43 years (range 17-63 years) and grouping was according to the HOST classification. Functional outcome was evaluated by a standardized questionnaire (Funktionsfragebogen Hannover FFbH-OA 2,0), quality of life and social reintegration by non-standardized questionnaires.

RESULTS

In the cases investigated the following results could be achieved: full leg activity 55%, leg pain while walking 73%, special footwear 68%, normal gait 55%, positive quality of life and social reintegration 55%, port activities 36% and reemployment 45%.

CONCLUSION

According to the results of this study the quality of life of patients with chronic osteitis of the lower leg is in general satisfying. In order to improve quality management and cost reduction in public health an interdisciplinary treatment concept of plastic and orthopedic surgeons should be established for complex fracture management as this is the most effective tool in treating chronic osteitis.