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Saúde-Conde R, El Ghali B, Navez J, Bouchart C, Van Laethem JL. Total Neoadjuvant Therapy in Localized Pancreatic Cancer: Is More Better? Cancers (Basel) 2024; 16:2423. [PMID: 39001485 PMCID: PMC11240662 DOI: 10.3390/cancers16132423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) poses a significant challenge in oncology due to its advanced stage upon diagnosis and limited treatment options. Surgical resection, the primary curative approach, often results in poor long-term survival rates, leading to the exploration of alternative strategies like neoadjuvant therapy (NAT) and total neoadjuvant therapy (TNT). While NAT aims to enhance resectability and overall survival, there appears to be potential for improvement, prompting consideration of alternative neoadjuvant strategies integrating full-dose chemotherapy (CT) and radiotherapy (RT) in TNT approaches. TNT integrates chemotherapy and radiotherapy prior to surgery, potentially improving margin-negative resection rates and enabling curative resection for locally advanced cases. The lingering question: is more always better? This article categorizes TNT strategies into six main groups based on radiotherapy (RT) techniques: (1) conventional chemoradiotherapy (CRT), (2) the Dutch PREOPANC approach, (3) hypofractionated ablative intensity-modulated radiotherapy (HFA-IMRT), and stereotactic body radiotherapy (SBRT) techniques, which further divide into (4) non-ablative SBRT, (5) nearly ablative SBRT, and (6) adaptive ablative SBRT. A comprehensive analysis of the literature on TNT is provided for both borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), with detailed sections for each.
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Affiliation(s)
- Rita Saúde-Conde
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Benjelloun El Ghali
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Julie Navez
- Department of Abdominal Surgery and Transplantation, Hôpitaux Universitaires de Bruxelles (HUB), Hopital Erasme, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Christelle Bouchart
- Department of Radiation Oncology, Hôpitaux Universitaires de Bruxelles (HUB), Institut Jules Bordet, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (B.E.G.); (C.B.)
| | - Jean-Luc Van Laethem
- Digestive Oncology Department, Hôpitaux Universitaires de Bruxelles (HUB), Université Libre de Bruxelles, 1070 Brussels, Belgium;
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2
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van Goor IWJM, Andel PCM, Buijs FS, Besselink MG, Bonsing BA, Bosscha K, Busch OR, Cirkel GA, van Dam RM, Festen S, Koerkamp BG, van der Harst E, de Hingh IHJT, Kazemier G, Liem MSL, Meijer G, de Meijer VE, Nieuwenhuijs VB, Roos D, Schreinemakers JMJ, Stommel MWJ, Wit F, Verdonk RC, van Santvoort HC, Molenaar IQ, Intven MPW, Daamen LA. Prediction of Isolated Local Recurrence After Resection of Pancreatic Ductal Adenocarcinoma: A Nationwide Study. Ann Surg Oncol 2024:10.1245/s10434-024-15664-4. [PMID: 38937412 DOI: 10.1245/s10434-024-15664-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Distinguishing postoperative fibrosis from isolated local recurrence (ILR) after resection of pancreatic ductal adenocarcinoma (PDAC) is challenging. A prognostic model that helps to identify patients at risk of ILR can assist clinicians when evaluating patients' postoperative imaging. This nationwide study aimed to develop a clinically applicable prognostic model for ILR after PDAC resection. PATIENTS AND METHODS An observational cohort study was performed, including all patients who underwent PDAC resection in the Netherlands (2014-2019; NCT04605237). On the basis of recurrence location (ILR, systemic, or both), multivariable cause-specific Cox-proportional hazard analysis was conducted to identify predictors for ILR and presented as hazard ratios (HRs) with 95% confidence intervals (CIs). A predictive model was developed using Akaike's Information Criterion, and bootstrapped discrimination and calibration indices were assessed. RESULTS Among 1194/1693 patients (71%) with recurrence, 252 patients (21%) developed ILR. Independent predictors for ILR were resectability status (borderline versus resectable, HR 1.42; 95% CI 1.03-1.96; P = 0.03, and locally advanced versus resectable, HR 1.11; 95% CI 0.68-1.82; P = 0.66), tumor location (head versus body/tail, HR 1.50; 95% CI 1.00-2.25; P = 0.05), vascular resection (HR 1.86; 95% CI 1.41-2.45; P < 0.001), perineural invasion (HR 1.47; 95% CI 1.01-2.13; P = 0.02), number of positive lymph nodes (HR 1.04; 95% CI 1.01-1.08; P = 0.02), and resection margin status (R1 < 1 mm versus R0 ≥ 1 mm, HR 1.64; 95% CI 1.25-2.14; P < 0.001). Moderate performance (concordance index 0.66) with adequate calibration (slope 0.99) was achieved. CONCLUSIONS This nationwide study identified factors predictive of ILR after PDAC resection. Our prognostic model, available through www.pancreascalculator.com , can be utilized to identify patients with a higher a priori risk of developing ILR, providing important information in patient evaluation and prognostication.
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Affiliation(s)
- I W J M van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands.
| | - P C M Andel
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - F S Buijs
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - M G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - B A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - K Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - O R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - G A Cirkel
- Department of Medical Oncology, University Medical Center Utrecht Cancer Center & Meander Medical Center Amersfoort, Regional Academic Cancer Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R M van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - S Festen
- Department of Surgery, OLVG, Amsterdam, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - E van der Harst
- Department of Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | - I H J T de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - G Kazemier
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, The Netherlands
| | - M S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - G Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - V E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - D Roos
- Department of Surgery, Renier de Graaf Gasthuis, Delft, The Netherlands
| | | | - M W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - R C Verdonk
- Department of Gastroenterology, Regional Academic Cancer Center Utrecht, Utrecht, The Netherlands
| | - H C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - I Q Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - M P W Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands
| | - L A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht University, University Medical Center Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands.
- Imaging Division, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
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3
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López Gonzalez M, Hernando-Requejo O, Ciervide Jurío R, Montero Luis Á, Saiz Guisasola C, Sánchez Saugar E, Álvarez Rodríguez B, Chen-Zhao X, García-Aranda M, Valero Albarran J, Alonso Gutierrez R, García Cañamaque L, Prados S, Quijano Y, de Vicente E, Rubio C. Prospective study on stereotactic body radiotherapy for small pancreatic neuroendocrine tumors: tolerance and effectiveness analysis. Clin Transl Oncol 2024:10.1007/s12094-024-03538-w. [PMID: 38907097 DOI: 10.1007/s12094-024-03538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/24/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Surgery is the standard treatment for pancreatic neuroendocrine tumors (pNETs), obtaining favorable results but associating high morbidity and mortality rates. This study assesses stereotactic body radiation therapy (SBRT) as a radical approach for small (< 2 cm) nonfunctioning pNETs. MATERIALS AND METHODS From January 2017 to June 2023, 20 patients with small pNETs underwent SBRT in an IRB-approved study. Endpoints included local control, tolerance, progression-free survival, and overall survival (OS). Diagnostic assessments comprised endoscopy, CT scans, OctreScan or PET-Dotatoc, abdominal MRI, and histological confirmatory samples. RESULTS In a 30-month follow-up of 20 patients (median age 55.5 years), SBRT was well-tolerated with no grade > 2 toxicity. 40% showed morphological response, 55% remained stable. Metabolically, 50% achieved significant improvement. With a median OS of 41.5 months, all patients were alive without local or distant progression or need for surgical resection. CONCLUSION SBRT is a feasible and well-tolerated approach for small neuroendocrine pancreatic tumors, demonstrating effective local control. Further investigations are vital for validation and extension of these findings.
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Affiliation(s)
- Mercedes López Gonzalez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain.
| | - Ovidio Hernando-Requejo
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Raquel Ciervide Jurío
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Ángel Montero Luis
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Carmen Saiz Guisasola
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Emilio Sánchez Saugar
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Beatriz Álvarez Rodríguez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Xin Chen-Zhao
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Mariola García-Aranda
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Jeannette Valero Albarran
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Rosa Alonso Gutierrez
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
| | - Lina García Cañamaque
- Department of Nuclear Medicine, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Susana Prados
- Department of Gastroenterology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Yolanda Quijano
- Department of Surgery, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Emilio de Vicente
- Department of Surgery, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Carmen Rubio
- Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, HM Hospitales, Oña 10, 28050, Madrid, Spain
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Hoffe SE, Aguilera TA, Parikh PJ, Ghaly MM, Herman JM, Caster JM, Kim DW, Costello J, Malafa MP, Moser EC, Kennedy EP, Terry K, Kurman M. Stereotactic body radiotherapy plus rucosopasem in locally advanced or borderline resectable pancreatic cancer: GRECO-2 phase II study design. Future Oncol 2024; 20:437-446. [PMID: 38264869 PMCID: PMC10988540 DOI: 10.2217/fon-2022-1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/02/2023] [Indexed: 01/25/2024] Open
Abstract
Ablative doses of stereotactic body radiotherapy (SBRT) may improve pancreatic cancer outcomes but may carry greater potential for gastrointestinal toxicity. Rucosopasem, an investigational selective dismutase mimetic that converts superoxide to hydrogen peroxide, can potentially increase tumor control of SBRT without compromising safety. GRECO-2 is a phase II, multicenter, randomized, double-blind, placebo-controlled trial of rucosopasem in combination with SBRT in locally advanced or borderline resectable pancreatic cancer. Patients will be randomized to rucosopasem 100 mg or placebo via intravenous infusion over 15 min, before each SBRT fraction (5 × 10 Gy). The primary end point is overall survival. Secondary end points include progression-free survival, locoregional control, time to metastasis, surgical resection rate, best overall response, in-field local response and acute and long-term toxicity.
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Affiliation(s)
- Sarah E Hoffe
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Maged M Ghaly
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Herman
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Caster
- Universty of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA
| | - Dae Won Kim
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - James Costello
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Mokenge P Malafa
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Kara Terry
- Galera Therapeutics, Inc., Malvern, PA 19355, USA
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5
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Shouman MA, Fuchs F, Walter F, Corradini S, Westphalen CB, Vornhülz M, Beyer G, Andrade D, Belka C, Niyazi M, Rogowski P. Stereotactic body radiotherapy for pancreatic cancer - A systematic review of prospective data. Clin Transl Radiat Oncol 2024; 45:100738. [PMID: 38370495 PMCID: PMC10873666 DOI: 10.1016/j.ctro.2024.100738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 02/20/2024] Open
Abstract
Purpose This systematic review aims to comprehensively summarize the current prospective evidence regarding Stereotactic Body Radiotherapy (SBRT) in various clinical contexts for pancreatic cancer including its use as neoadjuvant therapy for borderline resectable pancreatic cancer (BRPC), induction therapy for locally advanced pancreatic cancer (LAPC), salvage therapy for isolated local recurrence (ILR), adjuvant therapy after radical resection, and as a palliative treatment. Special attention is given to the application of magnetic resonance-guided radiotherapy (MRgRT). Methods Following PRISMA guidelines, a systematic review of the Medline database via PubMed was conducted focusing on prospective studies published within the past decade. Data were extracted concerning study characteristics, outcome measures, toxicity profiles, SBRT dosage and fractionation regimens, as well as additional systemic therapies. Results and conclusion 31 studies with in total 1,571 patients were included in this review encompassing 14 studies for LAPC, 9 for neoadjuvant treatment, 2 for adjuvant treatment, 2 for ILR, with an additional 4 studies evaluating MRgRT. In LAPC, SBRT demonstrates encouraging results, characterized by favorable local control rates. Several studies even report conversion to resectable disease with substantial resection rates reaching 39%. The adoption of MRgRT may provide a solution to the challenge to deliver ablative doses while minimizing severe toxicities. In BRPC, select prospective studies combining preoperative ablative-dose SBRT with modern induction systemic therapies have achieved remarkable resection rates of up to 80%. MRgRT also holds potential in this context. Adjuvant SBRT does not appear to confer relevant advantages over chemotherapy. While prospective data for SBRT in ILR and for palliative pain relief are limited, they corroborate positive findings from retrospective studies.
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Affiliation(s)
- Mohamed A Shouman
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Frederik Fuchs
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center (CCC Munich LMU), University Hospital LMU, Munich, Germany
| | - Marlies Vornhülz
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Georg Beyer
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Dorian Andrade
- Department of General, Visceral, and Transplant Surgery, University Hospital LMU, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Germany
| | - Paul Rogowski
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
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6
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Wang J, Gai J, Zhang T, Niu N, Qi H, Thomas DL, Li K, Xia T, Rodriguez C, Parkinson R, Durham J, McPhaul T, Narang AK, Anders RA, Osipov A, Wang H, He J, Laheru DA, Herman JM, Lee V, Jaffee EM, Thompson ED, Zhu Q, Zheng L. Neoadjuvant radioimmunotherapy in pancreatic cancer enhances effector T cell infiltration and shortens their distances to tumor cells. SCIENCE ADVANCES 2024; 10:eadk1827. [PMID: 38324679 PMCID: PMC10849596 DOI: 10.1126/sciadv.adk1827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Radiotherapy is hypothesized to have an immune-modulating effect on the tumor microenvironment (TME) of pancreatic ductal adenocarcinoma (PDAC) to sensitize it to anti-PD-1 antibody (a-PD-1) treatment. We collected paired pre- and posttreatment specimens from a clinical trial evaluating combination treatment with GVAX vaccine, a-PD-1, and stereotactic body radiation (SBRT) following chemotherapy for locally advanced PDACs (LAPC). With resected PDACs following different neoadjuvant therapies as comparisons, effector cells in PDACs were found to skew toward a more exhausted status in LAPCs following chemotherapy. The combination of GVAX/a-PD-1/SBRT drives TME to favor antitumor immune response including increased densities of GZMB+CD8+ T cells, TH1, and TH17, which are associated with longer survival, however increases immunosuppressive M2-like tumor-associated macrophages (TAMs). Adding SBRT to GVAX/a-PD-1 shortens the distances from PD-1+CD8+ T cells to tumor cells and to PD-L1+ myeloid cells, which portends prolonged survival. These findings have guided the design of next radioimmunotherapy studies by targeting M2-like TAM in PDACs.
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Affiliation(s)
- Junke Wang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Division of Biliary Tract Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jessica Gai
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Tengyi Zhang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Nan Niu
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Hanfei Qi
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Quantitative Sciences Division, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Dwayne L. Thomas
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Keyu Li
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Tao Xia
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Christina Rodriguez
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Rose Parkinson
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Jennifer Durham
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Thomas McPhaul
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amol K. Narang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Robert A. Anders
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Arsen Osipov
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Cedars Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Hao Wang
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Quantitative Sciences Division, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Jin He
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Daniel A. Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joseph M. Herman
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Northwell Health System, New Hyde Park, NY, 11042, USA
| | - Valerie Lee
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Elizabeth M. Jaffee
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Elizabeth D. Thompson
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Qingfeng Zhu
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Pancreatic Cancer Precision Medicine Center of Excellence Program, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Bloomberg Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Skip Viragh Pancreatic Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- The Cancer Convergence Institute at Johns Hopkins, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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7
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Gill GS, Hunt B, Zhang R, Williams BB, Zaki BI. Initial Observation of Contrast Profiles for 2-Dimensional and 3-Dimensional Magnetic Resonance Imaging Sequences in Magnetic Resonance-Guided Radiation Therapy for Locally Advanced Pancreatic Cancer. Adv Radiat Oncol 2024; 9:101314. [PMID: 38260228 PMCID: PMC10801635 DOI: 10.1016/j.adro.2023.101314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/03/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose In our experience treating locally advanced pancreatic cancer with magnetic resonance-guided radiation therapy (MRgRT), the true-fast imaging with steady-state free precession sequences used to generate both the real-time 2-dimensional (2D) magnetic resonance images (MRI; 2D cine) and the pretreatment high-resolution 3-dimensional (3D) MRI impart differing intensities for relevant structures between the 2 scans. Since these variations can confound target tracking selection, we propose that an understanding of the differing contrast profiles could improve selection of tracking structures. Methods and Materials We retrospectively reviewed both 2D cine and 3D MRI images for 20 patients with pancreatic cancer treated with MRgRT. At simulation, an appropriate tracking target was identified and contoured on a single 3-mm sagittal slice of the 3D MRI. This sagittal slice was directly compared with the coregistered 7-mm 2D cine to identify structures with notable discrepancies in signal intensity. The 3D MRI was then explored in additional planes to confirm structure identities. For quantitative verification of the clinically observed differences, the pixel intensity distributions of 2D cine and 3D MRI digital imaging and communications in medicine data sets were statistically compared. Results In all patients reviewed, arteries (aorta, celiac, superior mesenteric artery, hepatic artery) appeared mildly hyperintense on both scans. However, veins (portal vein, superior mesenteric vein) appeared hyperintense on 2D cine but isointense on 3D MRI. Biliary structures appeared mildly hyperintense on 2D cine but starkly hyperintense on 3D MRI. The pixel intensity distributions extracted from 2D cine and 3D MRI images were confirmed to differ significantly (2 sample Kolmogorov-Smirnov test; test statistic, 0.40; P < .001). Conclusions There are significant variations in image intensity between the immediate pretreatment 2D cine compared with the initial planning 3D MRI. Understanding variations of image intensity between the different MRI sequences used in MRgRT is valuable to radiation oncologists and may lead to improved target tracking and optimized treatment delivery.
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Affiliation(s)
- Gobind S. Gill
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, New Hampshire
| | - Brady Hunt
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, New Hampshire
| | - Rongxiao Zhang
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, New Hampshire
| | | | - Bassem I. Zaki
- Dartmouth Cancer Center, One Medical Center Drive, Lebanon, New Hampshire
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8
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Greenwood H, Hassan J, Fife K, Ajithkumar TV, Thippu Jayaprakash K. Single-Fraction Stereotactic Ablative Body Radiotherapy for Primary and Extracranial Oligometastatic Cancers. Clin Oncol (R Coll Radiol) 2023; 35:773-786. [PMID: 37852814 DOI: 10.1016/j.clon.2023.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/14/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
Stereotactic ablative body radiotherapy (SABR) consists of delivering high doses of ionising radiation, typically across three to eight fractions with high precision and conformity. SABR has become increasingly commonplace throughout the last quarter of a century and is offered for the treatment of various primary and metastatic tumour types. Delivering SABR in a single fraction has arisen as an appealing possibility for several reasons. These include fewer hospital visits, greater patient convenience, improved sustainability and lower costs. However, these factors must be balanced against considerations such as toxicity, side-effects and, most importantly, progression-free and overall survival. In this review we seek to analyse the results of studies looking at the efficacy of single-fraction SABR for lung, prostate, renal and pancreas primary tumours, as well as oligometastases. The tumour type to be most widely treated with single-fraction SABR is lung, but its remit continues to expand. We also look at the biological rationale underpinning SABR and how this can be extended to single-fraction regimens. Finally, we turn our attention towards the future directions of SABR and specifically single-fraction regimens. These include the possibility of combining SABR with immunotherapy and technological advances in the field, which could serve to expand the scope of SABR. We conclude by summarising the current clinical studies of single-fraction SABR.
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Affiliation(s)
- H Greenwood
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - J Hassan
- University College London Medical School, London, UK
| | - K Fife
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - T V Ajithkumar
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Thippu Jayaprakash
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Oncology, The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, UK.
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9
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Reyngold M, Karam SD, Hajj C, Wu AJ, Cuaron J, Lobaugh S, Yorke ED, Dickinson S, Jones B, Vinogradskiy Y, Shukla-Dave A, Do RKG, Sigel C, Zhang Z, Crane CH, Goodman KA. Phase 1 Dose Escalation Study of SBRT Using 3 Fractions for Locally Advanced Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2023; 117:53-63. [PMID: 36918130 PMCID: PMC11229378 DOI: 10.1016/j.ijrobp.2023.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/24/2023] [Accepted: 03/02/2023] [Indexed: 03/14/2023]
Abstract
PURPOSE The optimal dose and fractionation of stereotactic body radiation therapy (SBRT) for locally advanced pancreatic cancer (LAPC) have not been defined. Single-fraction SBRT was associated with more gastrointestinal toxicity, so 5-fraction regimens have become more commonly employed. We aimed to determine the safety and maximally tolerated dose of 3-fraction SBRT for LAPC. METHODS AND MATERIALS Two parallel phase 1 dose escalation trials were conducted from 2016 to 2019 at Memorial Sloan Kettering Cancer Center and University of Colorado. Patients with histologically confirmed LAPC without distant progression after at least 2 months of induction chemotherapy were eligible. Patients received 3-fraction linear accelerator-based SBRT at 3 dose levels, 27, 30, and 33 Gy, following a modified 3+3 design. Dose-limiting toxicity, defined as grade ≥3 gastrointestinal toxicity within 90 days, was scored by National Cancer Institute Common Terminology Criteria for Adverse Events, version 4. The secondary endpoints included cumulative incidence of local failure (LF) and distant metastasis (DM), as well as progression-free and overall survival PFS and OS, respectively, toxicity, and quality of life (QoL) using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30) and the pancreatic cancer-specific QLQ-PAN26 questionnaire. RESULTS Twenty-four consecutive patients were enrolled (27 Gy: 9, 30 Gy: 8, 33 Gy: 7). The median (range) age was 67 (52-79) years, and 12 (50%) had a head/uncinate tumor location, with a median tumor size of 3.8 (1.1-11) cm and CA19-9 of 60 (1-4880) U/mL. All received chemotherapy for a median of 4 (1.4-10) months. There were no grade ≥3 toxicities. Two-year rates (95% confidence interval) of LF, DM, PFS, and OS were 31.7% (8.6%-54.8%), 70.2% (49.7%-90.8%), 20.8% (4.6%-37.1%), and 29.2% (11.0%-47.4%), respectively. Three- and 6-month QoL assessment showed no detriment. CONCLUSIONS For select patients with LAPC, dose escalation to 33 Gy in 3 fractions resulted in no dose-limiting toxicities, no detriments to QoL, and disease outcomes comparable with conventional RT. Further exploration of SBRT schemes to maximize tumor control while enabling efficient integration with systemic therapy is warranted.
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Affiliation(s)
- Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Sana D Karam
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephanie Lobaugh
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Shannan Dickinson
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bernard Jones
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amita Shukla-Dave
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard Kinh Gian Do
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carlie Sigel
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
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10
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Falco M, Masojć B, Sulikowski T. Radiotherapy in Pancreatic Cancer: To Whom, When, and How? Cancers (Basel) 2023; 15:3382. [PMID: 37444492 DOI: 10.3390/cancers15133382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
The diagnosis rate of pancreatic cancer is steadily increasing. The average age of onset is close to 70 years. In most cases, the disease is diagnosed at an advanced stage. The indications for and techniques of radiotherapy are changing over time. The aim of this thesis is to present the role and possibilities of radiotherapy from the perspective of radiation oncologist. The most common cause of treatment failure in pancreatic cancer remains generalisation. The implementation of new systemic treatment regimens contributes to improved treatment outcomes regardless of the stage of the disease. With improved treatment outcomes in terms of the incidence of distant metastases, the impact of local curability on the length and quality of life of patients increases. Modern radiotherapy offers the opportunity to achieve high local cure rates. Postoperative radiotherapy in combination with chemotherapy seems justified in the group of postoperative pancreatic cancer patients with pT3 and pN+ features. In the group of patients with borderline resectable pancreatic cancer, the impact of radiotherapy in combination with the latest chemotherapy regimens is difficult to define clearly. In the setting of a diagnosis of advanced pancreatic cancer, radiotherapy, especially stereotactic radiotherapy, in combination with chemotherapy, contributes to improved local curability and allows to achieve a significantly reduced level of pain.
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Affiliation(s)
- Michał Falco
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
- Hospicjum Św. Jana Ewnagelisty, Pokoju 77, 71-740 Szczecin, Poland
| | - Bartłomiej Masojć
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Tadeusz Sulikowski
- Department of General, Minimally Invasive, and Gastroenterological Surgery, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland
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11
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Arcelli A, Tarantino G, Cellini F, Buwenge M, Macchia G, Bertini F, Guido A, Deodato F, Cilla S, Scotti V, Rosetto ME, Djan I, Parisi S, Mattiucci GC, Fiore M, Bonomo P, Belgioia L, Niespolo RM, Gabriele P, Di Marco M, Simoni N, Ma J, Strigari L, Mazzarotto R, Morganti AG. Comparative Effectiveness of Chemotherapy Alone Versus Radiotherapy-Based Regimens in Locally Advanced Pancreatic Cancer: A Real-World Multicenter Analysis (PAULA-1). Curr Oncol 2023; 30:5690-5703. [PMID: 37366910 DOI: 10.3390/curroncol30060427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/30/2023] [Accepted: 06/04/2023] [Indexed: 06/28/2023] Open
Abstract
Different options for locally advanced pancreatic cancer (LAPC) are available based on international guidelines: chemotherapy (CHT), chemoradiation (CRT), and stereotactic body radiotherapy (SBRT). However, the role of radiotherapy is debated in LAPC. We retrospectively compared CHT, CRT, and SBRT ± CHT in a real-world setting in terms of overall survival (OS), local control (LC), and distant metastasis-free survival (DMFS). LAPC patients from a multicentric retrospective database were included (2005-2018). Survival curves were calculated using the Kaplan-Meier method. Multivariable Cox analysis was performed to identify predictors of LC, OS, and DMFS. Of the 419 patients included, 71.1% were treated with CRT, 15.5% with CHT, and 13.4% with SBRT. Multivariable analysis showed higher LC rates for CRT (HR: 0.56, 95%CI 0.34-0.92, p = 0.022) or SBRT (HR: 0.27, 95%CI 0.13-0.54, p < 0.001), compared to CHT. CRT (HR: 0.44, 95%CI 0.28-0.70, p < 0.001) and SBRT (HR: 0.40, 95%CI 0.22-0.74, p = 0.003) were predictors of prolonged OS with respect to CHT. No significant differences were recorded in terms of DMFS. In selected patients, the addition of radiotherapy to CHT is still an option to be considered. In patients referred for radiotherapy, CRT can be replaced by SBRT considering its duration, higher LC rate, and OS rate, which are at least comparable to that of CRT.
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Affiliation(s)
- Alessandra Arcelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giuseppe Tarantino
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Francesco Cellini
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168 Rome, Italy
| | - Milly Buwenge
- Radiation Oncology, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, 40138 Bologna, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | - Federica Bertini
- Radiation Oncology Department, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, 33081 Aviano, Italy
| | - Alessandra Guido
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Francesco Deodato
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy
| | | | | | - Igor Djan
- Institute of Oncology Vojvodina, Sremska Kamenica, Medical Faculty, University of Novi Sad, 21204 Novi Sad, Serbia
| | - Salvatore Parisi
- Radiotherapy Unit, Ospedale Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Gian Carlo Mattiucci
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Radiation Oncology, Mater Olbia Hospital, 07026 Olbia, Italy
| | - Michele Fiore
- Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
- Operative Research Unit of Radiation Oncology, Fondazione Policlinico Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Pierluigi Bonomo
- Radiation Oncology, Azienda Ospedaliero Universitaria Careggi, 50134 Florence, Italy
| | - Liliana Belgioia
- Department of Radiotherapy, IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Health Science Departmente (DISSAL), University of Genoa, 16132 Genova, Italy
| | - Rita Marina Niespolo
- Radiation Oncology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy
| | - Pietro Gabriele
- Department of Radiotherapy, Fondazione del Piemonte per l'Oncologia (FPO), IRCCS Candiolo, 10060 Candiolo, Italy
| | - Mariacristina Di Marco
- Oncology Unit, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy
| | - Nicola Simoni
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
| | - Johnny Ma
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Radiation Oncology, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, 40138 Bologna, Italy
| | - Lidia Strigari
- Department of Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | | | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Radiation Oncology, Department of Medical and Surgical Sciences-DIMEC, University of Bologna, 40138 Bologna, Italy
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12
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Kamel R, Dennis K, Doody J, Pantarotto J. Ablative vs. Non-Ablative Radiotherapy in Palliating Locally Advanced Pancreatic Cancer: A Single Institution Experience and a Systematic Review of the Literature. Cancers (Basel) 2023; 15:cancers15113016. [PMID: 37296977 DOI: 10.3390/cancers15113016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
We studied the dose-local control (LC) relationship in ablative vs. non-ablative radiotherapy in a non-radical treatment setting of "locally advanced pancreatic cancer (LAPC)" by comparing our patients (n = 89) treated with SBRT on the CyberKnife unit vs. conventional radiation between January 2005 and January 2021, and by reviewing the literature. A systematic search was performed leveraging Medline for references on SBRT use in pancreatic cancer without date terms or language restrictions. A total of 3702 references were identified and the search was then repeated in Embase and the Cochrane database. Ultimately, 12 studies were eligible for inclusion, which either compared SBRT to conventional radiation, or SBRT use in dose escalation for primary LAPC in a non-neoadjuvant setting. Our cohort's median overall survival was 152 days (CI 95%, 118-185); including 371 days (CI 95%, 230-511) vs. 126 days (CI 95%, 90-161) favoring SBRT, p = 0.004. The median time to local progression was 170 days (48-923) for SBRT vs. 107 days (27-489) for the non-ablative group. In our SBRT patients, no local progressions were seen with BED10 > 60 Gy. Even when palliating LAPC, SBRT should be considered as an alternative to conventional radiation, especially in patients with a low disease burden. BED10 ≥ 60-70 Gy offers better local control without increasing toxicity rates. Less local progression may provide a better quality of life to those patients who already have a short life expectancy.
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Affiliation(s)
- Randa Kamel
- Department of Radiation Oncology, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
| | - Kristopher Dennis
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
| | - Janice Doody
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
| | - Jason Pantarotto
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
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13
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Wang ZM, Ma HB, Meng Y. Impact of chemoradiotherapy on the survival of unresectable locally advanced pancreatic cancer: a retrospective cohort analysis. BMC Gastroenterol 2023; 23:107. [PMID: 37020202 PMCID: PMC10077630 DOI: 10.1186/s12876-023-02739-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The role of chemoradiotherapy in unresectable locally advanced pancreatic cancer is still unclear. METHODS Data from patients with unresectable locally advanced pancreatic cancer were extracted from the Surveillance, Epidemiology, and End Results Program database. Univariate and multivariate Cox regression analyses were conducted to identify the independent prognostic factors of survival. Propensity score matching was carried out to minimize the interference of confounding factors. Subgroup analysis was performed to screen the characteristics of patients who would benefit from chemoradiotherapy. RESULTS A total of 5002 patients with unresectable locally advanced pancreatic cancer were included. Among them, 2423 (48.4%) received chemotherapy, and 2579 (51.6%) received chemoradiotherapy. The median overall survival of all patients was 11 months. Multivariate Cox analysis showed that age (p < 0.001), marital status (p < 0.001), tumor size (p = 0.001), N stage (p = 0.015) and radiotherapy (p < 0.001) were independent prognostic factors of survival. Both before (HR, 0.817; 95% CI, 0.769-0.868; p < 0.001) and after (HR, 0.904; 95% CI, 0.876-0.933; p < 0.001) propensity score matching, chemoradiotherapy significantly improved the median overall survival of patients from 10 to 12 months. Subgroup analysis showed that chemoradiotherapy was significantly associated with improved survival regardless of sex, primary site or N stage. In addition, the following subgroups all significantly benefited from chemoradiotherapy: age ≥ 50 years, not divorced, grade 2-4, tumor size > 2 cm, adenocarcinoma, mucinous adenocarcinoma and white race. CONCLUSIONS Chemoradiotherapy is highly recommended for patients with unresectable locally advanced pancreatic cancer.
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Affiliation(s)
- Zi-Meng Wang
- Department of Radiation Oncology, Third Affiliated Hospital of Naval Medical University (Eastern Hepatobiliary Surgery Hospital), Shanghai, 200438, China
| | - Hong-Bin Ma
- Department of Radiation Oncology, Third Affiliated Hospital of Naval Medical University (Eastern Hepatobiliary Surgery Hospital), Shanghai, 200438, China
| | - Yan Meng
- Department of Radiation Oncology, Third Affiliated Hospital of Naval Medical University (Eastern Hepatobiliary Surgery Hospital), Shanghai, 200438, China.
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14
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Hurmuz P, Cengiz M, Ozyigit G, Yuce Sari S, Kahvecioglu A, Beduk Esen CS, Yalcin S, Zorlu F. Stereotactic Body Radiotherapy as an Effective Treatment for Pancreatic Cancer. Cureus 2023; 15:e38255. [PMID: 37252548 PMCID: PMC10225161 DOI: 10.7759/cureus.38255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/31/2023] Open
Abstract
Background Stereotactic body radiotherapy (SBRT) allows the delivery of an ablative radiation dose to the tumor with minimal toxicity. Although magnetic resonance imaging (MRI)-guided SBRT appears to be a promising approach in the modern era, X-ray image-guided SBRT is still used worldwide for pancreatic cancer. This study aims to evaluate the results of X-ray image-guided SBRT in patients with locally advanced pancreatic cancer (LAPC). Methodology Medical records of 24 patients with unresectable LAPC who underwent X-ray image-guided SBRT between 2009 and 2022 were retrospectively evaluated. SPSS version 23.0 (IBM Corp., Armonk, NY, USA) was utilized for all analyses. Results The median age was 64 years (range = 42-81 years), and the median tumor size was 3.5 cm (range = 2.7-4 cm). The median total dose of SBRT was 35 Gy (range = 33-50 Gy) in five fractions. After SBRT, 30% of patients showed complete and 41% showed partial response, whereas 20% had stable disease and 9% had progression. Median follow-up was 15 months (range = 6-58 months). During follow-up, four (16%) patients had local recurrence, one (4%) had a regional recurrence, and 17 (70%) had distant metastasis (DM). The two-year local control (LC), local recurrence-free survival (LRFS), overall survival (OS), and DM-free survival (DMFS) rate was 87%, 36%, 37%, and 29%, respectively. In univariate analysis, a larger tumor size (>3.5 cm) and higher cancer antigen 19-9 level (>106.5 kU/L) significantly decreased the OS, LRFS, and DMFS rates. No severe acute toxicity was observed. However, two patients had severe late toxicity as intestinal bleeding. Conclusions X-ray image-guided SBRT provides a good LC rate with minimal toxicity for unresectable LAPC. However, despite modern systemic treatments, the rate of DM remains high which plays a major role in survival.
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Affiliation(s)
- Pervin Hurmuz
- Radiation Oncology, Hacettepe University Medical School, Ankara, TUR
| | - Mustafa Cengiz
- Radiation Oncology, Hacettepe University Medical School, Ankara, TUR
| | - Gokhan Ozyigit
- Radiation Oncology, Hacettepe University Medical School, Ankara, TUR
| | - Sezin Yuce Sari
- Radiation Oncology, Hacettepe University Medical School, Ankara, TUR
| | - Alper Kahvecioglu
- Radiation Oncology, Hacettepe University Medical School, Ankara, TUR
| | | | - Suayib Yalcin
- Medical Oncology, Hacettepe University Medical School, Ankara, TUR
| | - Faruk Zorlu
- Radiation Oncology, Hacettepe University Medical School, Ankara, TUR
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15
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Hill CS, Herman JM. The Current Role of Radiation in Pancreatic Cancer and Future Directions. Clin Colorectal Cancer 2023; 22:12-23. [PMID: 36804206 DOI: 10.1016/j.clcc.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
Survival outcomes for localized pancreatic adenocarcinoma remains poor. Multimodality therapeutic regimens are critical to maximizing survival outcomes for these patients, which includes the use of systemic therapy, surgery, and radiation. In this review, the evolution of radiation techniques are discussed with a focus on modern techniques such as intensity modulated radiation and stereotactic body radiation therapy. However, the current role of radiation within the most common clinical scenarios for pancreatic cancer in the neoadjuvant, definitive, and adjuvant settings continues to be highly debated. The role of radiation in these settings is reviewed in the context of historical and modern clinical studies. In addition, emerging concepts including dose-escalated radiation, magnetic resonance-guided radiation therapy, and particle therapy are discussed to promote an understanding of how such concepts may change the role of radiation in the future.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY.
| | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
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16
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Lee M, Kang JS, Kim H, Kwon W, Lee SH, Ryu JK, Kim YT, Oh DY, Chie EK, Jang JY. Impact of conversion surgery on survival in locally advanced pancreatic cancer patients treated with FOLFIRINOX chemotherapy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:111-121. [PMID: 34581022 DOI: 10.1002/jhbp.1050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/13/2021] [Accepted: 09/20/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Locally advanced (unresectable) pancreatic cancer (LAPC) is surgically unresectable and often treated with chemotherapy. Most previous studies, that have evaluated conversion surgery after chemotherapy, included heterogeneous patients and chemotherapy regimens, making it challenging to determine the impact of FOLFIRINOX. The present study evaluated the survival benefit of conversion surgery in patients with LAPC who received FOLFIRINOX chemotherapy, and analyzed the prognostic factors. METHODS Patients with LAPC who received FOLFIRINOX as first-line therapy for at least four cycles were included. During chemotherapy, surgical eligibility was determined based on radiologic and metabolic response to the treatment. Clinicopathologic characteristics were compared between the curative-intent surgery and non-resection groups, and the prognostic factors were analyzed. RESULTS A total of 279 patients were included. The rates of partial response (PR) and stable disease (SD) were 34.1% and 51.4%, respectively, and 16.8% patients underwent curative-intent surgery. The median survival was significantly longer in the resection group than in the non-resection group (56 vs 21 months, P < .001). In a multivariate analysis, curative-intent surgery (HR 0.260; P < .001) was the most important factor. CONCLUSIONS Conversion surgery after FOLFIRINOX chemotherapy effectively rescues patients with LAPC. Patients without progression after FOLFIRINOX could be considered as potential candidates for conversion surgery.
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Affiliation(s)
- Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Kon Ryu
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yong-Tae Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Youn Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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17
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Hill CS, Rosati L, Wang H, Tsai HL, He J, Hacker-Prietz A, Laheru DA, Zheng L, Sehgal S, Bernard V, Le DT, Pawlik TM, Weiss MJ, Narang AK, Herman JM. Multiagent Chemotherapy and Stereotactic Body Radiation Therapy in Patients with Unresectable Pancreatic Adenocarcinoma: A Prospective Nonrandomized Controlled Trial. Pract Radiat Oncol 2022; 12:511-523. [PMID: 35306231 PMCID: PMC9516435 DOI: 10.1016/j.prro.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/22/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE In a prospective multicenter study, gemcitabine monotherapy followed by stereotactic body radiation therapy (SBRT) was well tolerated with outcomes comparable to chemoradiation for locally advanced pancreatic cancer (LAPC). Recent trials have reported improved survival with multiagent chemotherapy (MA-CTX) alone. This prospective trial explored whether SBRT could be safely delivered after MA-CTX. Herein, we report the long-term outcomes of adding SBRT after MA-CTX in LAPC patients and evaluate whether genetic profiles of specimens obtained before SBRT influence outcomes. METHODS AND MATERIALS This prospective nonrandomized controlled phase 2 trial enrolled 44 LAPC and 4 locally recurrent patients after multidisciplinary evaluation between 2012 and 2015 at a high-volume pancreatic cancer center. For induction CTX, most received modified FOLFIRINOX (mFFX), or gemcitabine and nab-paclitaxel (GnP) followed by 5-fraction SBRT for all. During fiducial placement, biopsies were obtained with DNA extracted for targeted sequencing using the Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets platform. RESULTS Median induction CTX duration was ≥4 months, and 31 patients received mFFX (65%). Among 44 LAPC patients, 17 (39%) were surgically explored, and 12 of 16 (75%) achieved a R0 resection. Median overall survival (mOS) was 20.2 and 14.6 months from diagnosis and SBRT, respectively. One- and 2-year OS from SBRT was 58% and 28%. The mOS after resection was 28.6 and 22.4 months from diagnosis and SBRT, respectively. Median local progression-free survival was 23.9 and 15.8 months from diagnosis and SBRT, respectively. The mOS for pre-SBRT CA 19-9 ≤180 U/mL versus >180 was 23.1 and 11.3 months, respectively (hazard ratio, 0.53; P = .04). Only 1 patient (2.1%) had late grade ≥2 gastrointestinal toxic effects attributable to SBRT. Despite significant pretreatment with chemotherapy, 88% of tumor specimens were effectively sequenced; survival outcomes were not significantly associated with specific mutational patterns. Quality of life was prospectively collected pre- and post-SBRT with the EORTC QLQ-C30 and PAN26 questionnaires showing no significant change. CONCLUSIONS SBRT was safely administered with MA-CTX with minimal toxicity. A high proportion of LAPC patients underwent R0 resection with favorable survival outcomes.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lauren Rosati
- University of South Carolina School of Medicine, Columbia, South Carolina
| | - Hao Wang
- Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hua-Ling Tsai
- Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amy Hacker-Prietz
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel A Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shuchi Sehgal
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Vincent Bernard
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dung T Le
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, Ohio State Comprehensive Cancer Center, Columbus, Ohio
| | - Matthew J Weiss
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Amol K Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success and Zucker School of Medicine, Hempstead, New York.
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18
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van Goor IWJM, Daamen LA, Besselink MG, Bruynzeel AME, Busch OR, Cirkel GA, Groot Koerkamp B, Haj Mohammed N, Heerkens HD, van Laarhoven HWM, Meijer GJ, Nuyttens J, van Santvoort HC, van Tienhoven G, Verkooijen HM, Wilmink JW, Molenaar IQ, Intven MPW. A nationwide randomized controlled trial on additional treatment for isolated local pancreatic cancer recurrence using stereotactic body radiation therapy (ARCADE). Trials 2022; 23:913. [PMID: 36307892 PMCID: PMC9617359 DOI: 10.1186/s13063-022-06829-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/06/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Disease recurrence is the main cause of mortality after resection of pancreatic ductal adenocarcinoma (PDAC). In 20-30% of resected patients, isolated local PDAC recurrence occurs. Retrospective studies have suggested that stereotactic body radiation therapy (SBRT) might lead to improved local control in these patients, potentially having a beneficial effect on both survival and quality of life. The "nationwide randomized controlled trial on additional treatment for isolated local pancreatic cancer recurrence using stereotactic body radiation therapy" (ARCADE) will investigate the value of SBRT in addition to standard of care in patients with isolated local PDAC recurrence compared to standard of care alone, regarding both survival and quality of life outcomes. METHODS The ARCADE trial is nested within a prospective cohort (Dutch Pancreatic Cancer Project; PACAP) according to the 'Trials within Cohorts' design. All PACAP participants with isolated local PDAC recurrence after primary resection who provided informed consent for being randomized in future studies are eligible. Patients will be randomized for local therapy (5 fractions of 8 Gy SBRT) in addition to standard of care or standard of care alone. In total, 174 patients will be included. The main study endpoint is survival after recurrence. The most important secondary endpoint is quality of life. DISCUSSION It is hypothesized that additional SBRT, compared to standard of care alone, improves survival and quality of life in patients with isolated local recurrence after PDAC resection. TRIAL REGISTRATION ClinicalTrials.gov registration NCT04881487 . Registered on May 11, 2021.
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Affiliation(s)
- I. W. J. M. van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands ,Nieuwegein, the Netherlands ,Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - L. A. Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands ,Nieuwegein, the Netherlands ,grid.7692.a0000000090126352Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M. G. Besselink
- grid.7177.60000000084992262Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - A. M. E. Bruynzeel
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands ,grid.509540.d0000 0004 6880 3010Department of Radiation Oncology, Amsterdam University Medical Center, location Vrije Universiteit, Amsterdam, the Netherlands
| | - O. R. Busch
- grid.7177.60000000084992262Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands ,grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands
| | - G. A. Cirkel
- Department of Medical Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - B. Groot Koerkamp
- grid.5645.2000000040459992XDepartment of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - H. D. Heerkens
- grid.10417.330000 0004 0444 9382Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - H. W. M. van Laarhoven
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands ,grid.509540.d0000 0004 6880 3010Department of Medical Oncology, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, the Netherlands
| | - G. J. Meijer
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
| | - J. Nuyttens
- grid.5645.2000000040459992XDepartment of Radiation Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - H. C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands ,Nieuwegein, the Netherlands
| | - G. van Tienhoven
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands ,grid.7177.60000000084992262Department of Radiation Oncology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - H. M. Verkooijen
- grid.7692.a0000000090126352Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - J. W. Wilmink
- grid.16872.3a0000 0004 0435 165XCancer Center Amsterdam, Amsterdam, the Netherlands ,grid.509540.d0000 0004 6880 3010Department of Medical Oncology, Amsterdam University Medical Center, location University of Amsterdam, Amsterdam, the Netherlands
| | - I. Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands ,Nieuwegein, the Netherlands
| | - M. P. W. Intven
- Department of Radiation Oncology, Regional Academic Cancer Center Utrecht, Utrecht, the Netherlands
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19
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Burkoň P, Trna J, Slávik M, Němeček R, Kazda T, Pospíšil P, Dastych M, Eid M, Novotný I, Procházka T, Vrzal M. Stereotactic Body Radiotherapy (SBRT) of Pancreatic Cancer-A Critical Review and Practical Consideration. Biomedicines 2022; 10:biomedicines10102480. [PMID: 36289742 PMCID: PMC9599229 DOI: 10.3390/biomedicines10102480] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/18/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Pancreatic cancer is the third leading cause of cancer death in the developed world and is predicted to become the second by 2030. A cure may be achieved only with surgical resection of an early diagnosed disease. Surgery for more advanced disease is challenging and can be contraindicated for many reasons. Neoadjuvant therapy may improve the probability of achieving R0 resection. It consists of systemic treatment followed by radiation therapy applied concurrently or sequentially with cytostatics. A novel approach to irradiation, stereotactic body radiotherapy (SBRT), has the potential to improve treatment results. SBRT can deliver higher doses of radiation to the tumor in only a few treatment fractions. It has attracted significant interest for pancreatic cancer patients, as it is completed quickly, requires less time away from full-dose chemotherapy, and is well-tolerated than conventional radiotherapy. In this review, we aim to provide the reader with a basic overview of current evidence for SBRT indications in the treatment of pancreatic tumors. In the second part of the review, we focus on practical information with respect to SBRT treatment plan preparation the performance of such therapy. Finally, we discuss future directions related to the use of magnetic resonance linear accelerators.
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Affiliation(s)
- Petr Burkoň
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Jan Trna
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Marek Slávik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Radim Němeček
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Petr Pospíšil
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Milan Dastych
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Michal Eid
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Ivo Novotný
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Procházka
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
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20
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Schaal JL, Bhattacharyya J, Brownstein J, Strickland KC, Kelly G, Saha S, Milligan J, Banskota S, Li X, Liu W, Kirsch DG, Zalutsky MR, Chilkoti A. Brachytherapy via a depot of biopolymer-bound 131I synergizes with nanoparticle paclitaxel in therapy-resistant pancreatic tumours. Nat Biomed Eng 2022; 6:1148-1166. [PMID: 36261625 PMCID: PMC10389695 DOI: 10.1038/s41551-022-00949-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 09/06/2022] [Indexed: 12/14/2022]
Abstract
Locally advanced pancreatic tumours are highly resistant to conventional radiochemotherapy. Here we show that such resistance can be surmounted by an injectable depot of thermally responsive elastin-like polypeptide (ELP) conjugated with iodine-131 radionuclides (131I-ELP) when combined with systemically delivered nanoparticle albumin-bound paclitaxel. This combination therapy induced complete tumour regressions in diverse subcutaneous and orthotopic mouse models of locoregional pancreatic tumours. 131I-ELP brachytherapy was effective independently of the paclitaxel formulation and dose, but external beam radiotherapy (EBRT) only achieved tumour-growth inhibition when co-administered with nanoparticle paclitaxel. Histological analyses revealed that 131I-ELP brachytherapy led to changes in the expression of intercellular collagen and junctional proteins within the tumour microenvironment. These changes, which differed from those of EBRT-treated tumours, correlated with the improved delivery and accumulation of paclitaxel nanoparticles within the tumour. Our findings support the further translational development of 131I-ELP depots for the synergistic treatment of localized pancreatic cancer.
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Affiliation(s)
- Jeffrey L Schaal
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Jayanta Bhattacharyya
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
- Center for Biomedical Engineering, Indian Institute of Technology Delhi, Hauz Khas, New Delhi, India
| | - Jeremy Brownstein
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Kyle C Strickland
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Garrett Kelly
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Soumen Saha
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Joshua Milligan
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Samagya Banskota
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Xinghai Li
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Wenge Liu
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - David G Kirsch
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
- Department of Pharmacology & Cancer Biology, Duke University Medical Center, Durham, NC, USA
| | - Michael R Zalutsky
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Ashutosh Chilkoti
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.
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21
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Association of survival with stereotactic body radiation therapy following induction chemotherapy for unresected locally advanced pancreatic cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2022; 21:403-410. [DOI: 10.1017/s1460396921000212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractAim:Induction chemotherapy (iC) followed by concurrent chemoradiation has been shown to improve overall survival (OS) for locally advanced pancreatic cancer (LAPC). However, the survival benefit of stereotactic body radiation therapy (SBRT) versus conventionally fractionated radiation therapy (CFRT) following iC remains unclear.Materials and methods:The National Cancer Database (NCDB) was queried for primary stage III, cT4N0-1M0 LAPC (2004–15). Kaplan–Meier analysis, Cox proportional hazards method and propensity score matching were used.Results:Among 872 patients, 738 patients underwent CFRT and 134 patients received SBRT. Median follow-up was 24·3 and 22·9 months for the CFRT and SBRT cohorts, respectively. The use of SBRT showed improved survival in both the multivariate analysis (hazards ratio 0·78, p = 0·025) and 120 propensity-matched pairs (median OS 18·1 versus 15·9 months, p = 0·004) compared to the CFRT.Findings:This NCDB analysis suggests survival benefit with the use of SBRT versus CFRT following iC for the LAPC.
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22
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Nguyen NQ. Editorial: Management of pancreatic cancer: Defining the targets for therapy. Front Med (Lausanne) 2022; 9:971067. [PMID: 35991654 PMCID: PMC9382291 DOI: 10.3389/fmed.2022.971067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nam Q. Nguyen
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia
- School of Medicine, University of Adelaide, Adelaide, SA, Australia
- *Correspondence: Nam Q. Nguyen
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23
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Ji X, Zhou B, Ding W, Wang J, Jiang W, Li Y, Hu J, Sun X. Efficacy of stereotactic body radiation therapy for locoregional recurrent pancreatic cancer after radical resection. Front Oncol 2022; 12:925043. [PMID: 35936670 PMCID: PMC9353056 DOI: 10.3389/fonc.2022.925043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022] Open
Abstract
Objective This study aimed to analyze the efficacy and toxicity of stereotactic body radiotherapy (SBRT) for locoregional recurrent pancreatic cancer after radical resection. Methods Patients with locoregional recurrent pancreatic cancer after surgery treated with SBRT in our institution were retrospectively investigated from January 2010 to January 2020. Absolute neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) recorded at pretreatment were analyzed. Endpoints included overall survival (OS), progression-free survival (PFS) and cumulative incidences of local failure (LF) and metastatic failure (MF). Results A total of 22 patients received SBRT with a median prescribed dose of 40 Gy (range of 30-50 Gy)/4 to 7 fractions. The median OS of all patients was 13.6 months (95% CI, 9.6-17.5 months). 0-1 performance status (HR 12.10, 95% CI 2.04-71.81, P=0.006) and ≤2.1 pre-SBRT NLR (HR 4.05, 95% CI 1.21-13.59, P=0.023) were significant predictors of higher OS on multivariable analysis. The median progression-free survival (PFS) of the cohort was 7.5 months (95% CI, 6.5-8.5 months). The median time to LF and MF were 15.6 months and 6.4 months, respectively. The rate of MF as a first event was higher than that of first event LF. Pain relief was observed in all patients (100%) 6 weeks after SBRT. In terms of acute toxicity, grade 1 including fatigue (6, 27.3%), anorexia (6, 27.3%), nausea (4, 18.2%) and leukopenia (4, 18.2%) was often observed. No acute toxicity of grade 4 or 5 was observed. In terms of late toxicity, no treatment-related toxicity was found during follow-up. Conclusion This study showed that SBRT can significantly reduce pain, effectively control local tumor progression, and have acceptable toxicity for patients with locoregional recurrence after radical resection of primary pancreatic cancer. Good performance status and lower pre-SBRT NLR were associated with improved overall survival.
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Janssen QP, van Dam JL, Prakash LR, Doppenberg D, Crane CH, van Eijck CHJ, Ellsworth SG, Jarnagin WR, O'Reilly EM, Paniccia A, Reyngold M, Besselink MG, Katz MHG, Tzeng CWD, Zureikat AH, Groot Koerkamp B, Wei AC. Neoadjuvant Radiotherapy After (m)FOLFIRINOX for Borderline Resectable Pancreatic Adenocarcinoma: A TAPS Consortium Study. J Natl Compr Canc Netw 2022; 20:783-791.e1. [PMID: 35830887 DOI: 10.6004/jnccn.2022.7008] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 01/28/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The value of neoadjuvant radiotherapy (RT) after 5-fluorouracil with leucovorin, oxaliplatin, and irinotecan, with or without dose modifications [(m)FOLFIRINOX], for patients with borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) is uncertain. METHODS We conducted an international retrospective cohort study including consecutive patients with BR PDAC who received (m)FOLFIRINOX as initial treatment (2012-2019) from the Trans-Atlantic Pancreatic Surgery Consortium. Because the decision to administer RT is made after chemotherapy, patients with metastases or deterioration after (m)FOLFIRINOX or a performance score ≥2 were excluded. Patients who received RT after (m)FOLFIRINOX were matched 1:1 by nearest neighbor propensity scores with patients who did not receive RT. Propensity scores were calculated using sex, age (≤70 vs >70 years), WHO performance score (0 vs 1), tumor size (0-20 vs 21-40 vs >40 mm), tumor location (head/uncinate vs body/tail), number of cycles (1-4 vs 5-8 vs >8), and baseline CA 19-9 level (≤500 vs >500 U/mL). Primary outcome was overall survival (OS) from diagnosis. RESULTS Of 531 patients who received neoadjuvant (m)FOLFIRINOX for BR PDAC, 424 met inclusion criteria and 300 (70.8%) were propensity score-matched. After matching, median OS was 26.2 months (95% CI, 24.0-38.4) with RT versus 32.8 months (95% CI, 25.3-42.0) without RT (P=.71). RT was associated with a lower resection rate (55.3% vs 72.7%; P=.002). In patients who underwent a resection, RT was associated with a comparable margin-negative resection rate (>1 mm) (70.6% vs 64.8%; P=.51), more node-negative disease (57.3% vs 37.6%; P=.01), and more major pathologic response with <5% tumor viability (24.7% vs 8.3%; P=.006). The OS associated with conventional and stereotactic body RT approaches was similar (median OS, 25.7 vs 26.0 months; P=.92). CONCLUSIONS In patients with BR PDAC, neoadjuvant RT following (m)FOLFIRINOX was associated with more node-negative disease and better pathologic response in patients who underwent resection, yet no difference in OS was found. Routine use of RT cannot be recommended based on these data.
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Affiliation(s)
- Quisette P Janssen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York;,Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Deesje Doppenberg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Susannah G Ellsworth
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eileen M O'Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; and
| | - Alessandro Paniccia
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amer H Zureikat
- Department of Surgery, Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Kaučić H, Kosmina D, Schwarz D, Mack A, Šobat H, Čehobašić A, Leipold V, Andrašek I, Avdičević A, Mlinarić M. Stereotactic Ablative Radiotherapy Using CALYPSO ® Extracranial Tracking for Intrafractional Tumor Motion Management-A New Potential Local Treatment for Unresectable Locally Advanced Pancreatic Cancer? Results from a Retrospective Study. Cancers (Basel) 2022; 14:cancers14112688. [PMID: 35681668 PMCID: PMC9179494 DOI: 10.3390/cancers14112688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/24/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: The aim of this study was to evaluate the efficacy and safety of SABR for LAPC using Calypso® Extracranial Tracking for intrafractional, fiducial-based motion management, to present this motion management technique, as there are yet no published data on usage of Calypso® during SABR for LAPC, and to report on our clinical outcomes. (2) Methods: Fifty-four patients were treated with SABR in one, three, or five fractions, receiving median BED10 = 112.5 Gy. Thirty-eight patients received systemic treatment. End points were OS, FFLP, PFS, and toxicity. Actuarial survival analysis and univariate analysis were investigated. (3) Results: Median follow-up was 20 months. Median OS was 24 months. One-year FFLP and one-year OS were 100% and 90.7%, respectively. Median PFS was 18 months, and one-year PFS was 72.2%. Twenty-five patients (46.3%) were alive at the time of analysis, and both median FU and OS for this subgroup were 26 months. No acute/late toxicity > G2 was reported. (4) Conclusions: SABR for LAPC using Calypso® presented as an effective and safe treatment and could be a promising local therapeutic option with very acceptable toxicity, either as a single treatment or in a multimodality regimen. Dose escalation to the tumor combined with systemic treatment could yield better clinical outcomes.
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Affiliation(s)
- Hrvoje Kaučić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
- Correspondence: ; Tel.: +385-91-5622-191
| | - Domagoj Kosmina
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Dragan Schwarz
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Medicinski Fakultet Sveučilišta u Rijeci, Braće Branchetta 20/1, 51000 Rijeka, Croatia
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Fakultet za Dentalnu Medicinu i Zdravstvo Osijek, Crkvena Ulica 21, 31000 Osijek, Croatia
| | - Andreas Mack
- Swiss NeuroRadiosurgery Center, Bürglistrasse 29, 8002 Zürich, Switzerland;
| | - Hrvoje Šobat
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Adlan Čehobašić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Vanda Leipold
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
- Sveučilište Josipa Jurja Strossmayera u Osijeku—Medicinski Fakultet Osijek, Josipa Huttlera 4, 31000 Osijek, Croatia
| | - Iva Andrašek
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Asmir Avdičević
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
| | - Mihaela Mlinarić
- Specijalna bolnica Radiochirurgia Zagreb, Ulica Dr. Franje Tuđmana 4, 10431 Sveta Nedelja, Croatia; (D.K.); (D.S.); (H.Š.); (A.Č.); (V.L.); (I.A.); (A.A.); (M.M.)
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Buwenge M, Arcelli A, Cellini F, Deodato F, Macchia G, Cilla S, Galietta E, Strigari L, Malizia C, Cammelli S, Morganti AG. Pain Relief after Stereotactic Radiotherapy of Pancreatic Adenocarcinoma: An Updated Systematic Review. Curr Oncol 2022; 29:2616-2629. [PMID: 35448188 PMCID: PMC9032429 DOI: 10.3390/curroncol29040214] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/23/2022] [Accepted: 04/06/2022] [Indexed: 02/07/2023] Open
Abstract
Severe pain is frequent in patients with locally advanced pancreatic ductal adenocarcinoma (PDCA). Stereotactic body radiotherapy (SBRT) provides high local control rates in these patients. The aim of this review was to systematically analyze the available evidence on pain relief in patients with PDCA. We updated our previous systematic review through a search on PubMed of papers published from 1 January 2018 to 30 June 2021. Studies with full available text, published in English, and reporting pain relief after SBRT on PDCA were included in this analysis. Statistical analysis was carried out using the MEDCALC statistical software. All tests were two-sided. The I2 statistic was used to quantify statistical heterogeneity (high heterogeneity level: >50%). Nineteen papers were included in this updated literature review. None of them specifically aimed at assessing pain and/or quality of life. The rate of analgesics reduction or suspension ranged between 40.0 and 100.0% (median: 60.3%) in six studies. The pooled rate was 71.5% (95% CI, 61.6−80.0%), with high heterogeneity between studies (Q2 test: p < 0.0001; I2 = 83.8%). The rate of complete response of pain after SBRT ranged between 30.0 and 81.3% (median: 48.4%) in three studies. The pooled rate was 51.9% (95% CI, 39.3−64.3%), with high heterogeneity (Q2 test: p < 0.008; I2 = 79.1%). The rate of partial plus complete pain response ranged between 44.4 and 100% (median: 78.6%) in nine studies. The pooled rate was 78.3% (95% CI, 71.0−84.5%), with high heterogeneity (Q2 test: p < 0.0001; I2 = 79.4%). A linear regression with sensitivity analysis showed significantly improved overall pain response as the EQD2α/β:10 increases (p: 0.005). Eight papers did not report any side effect during and after SBRT. In three studies only transient acute effects were recorded. The results of the included studies showed high heterogeneity. However, SBRT of PDCA resulted reasonably effective in producing pain relief in these patients. Further studies are needed to assess the impact of SBRT in this setting based on Patient-Reported Outcomes.
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Affiliation(s)
- Milly Buwenge
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (E.G.); (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine—DIMES, Alma Mater Studiorum University of Bologna, Via Albertoni 15, 40138 Bologna, Italy
| | - Alessandra Arcelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (E.G.); (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine—DIMES, Alma Mater Studiorum University of Bologna, Via Albertoni 15, 40138 Bologna, Italy
| | - Francesco Cellini
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (F.C.); (F.D.)
- Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC di Radioterapia, 00168 Roma, Italy
| | - Francesco Deodato
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, 00168 Roma, Italy; (F.C.); (F.D.)
- Radiotherapy Unit, Gemelli Molise Hospital, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 1, 86100 Campobasso, Italy;
| | - Gabriella Macchia
- Radiotherapy Unit, Gemelli Molise Hospital, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 1, 86100 Campobasso, Italy;
| | - Savino Cilla
- Medical Physic Unit, Gemelli Molise Hospital, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Largo Agostino Gemelli 1, 86100 Campobasso, Italy;
| | - Erika Galietta
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (E.G.); (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine—DIMES, Alma Mater Studiorum University of Bologna, Via Albertoni 15, 40138 Bologna, Italy
| | - Lidia Strigari
- Medical Physics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Claudio Malizia
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Silvia Cammelli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (E.G.); (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine—DIMES, Alma Mater Studiorum University of Bologna, Via Albertoni 15, 40138 Bologna, Italy
| | - Alessio G. Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (A.A.); (E.G.); (S.C.); (A.G.M.)
- Department of Experimental, Diagnostic and Specialty Medicine—DIMES, Alma Mater Studiorum University of Bologna, Via Albertoni 15, 40138 Bologna, Italy
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Shin YS, Park HH, Park JH, Seo DW, Lee SS, Yoo C, Kim S, Yoon SM, Jung J, Kim MH, Lee SK, Park DH, Song TJ, Oh D, Ryoo BY, Chang HM, Kim KP, Jeong JH, Kim JH. Stereotactic Body Radiation Therapy versus Concurrent Chemoradiotherapy for Locally Advanced Pancreatic Cancer: A Propensity Score-Matched Analysis. Cancers (Basel) 2022; 14:cancers14051166. [PMID: 35267485 PMCID: PMC8909663 DOI: 10.3390/cancers14051166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 01/02/2023] Open
Abstract
In locally advanced pancreatic cancer (LAPC), stereotactic body radiation therapy (SBRT) has been applied as an alternative to concurrent chemoradiotherapy (CCRT); however, direct comparative evidence between these two modalities is scarce. The aim of this study was to compare the clinical outcomes of SBRT with CCRT for LAPC. We retrospectively reviewed the medical records of patients with LAPC who received SBRT (n = 95) or CCRT (n = 66) with a concurrent 5-FU-based regimen between January 2008 and July 2016. The clinical outcomes of freedom from local progression (FFLP), progression-free survival (PFS), overall survival (OS), and toxicities were analyzed before and after propensity score (PS) matching. After a median follow-up duration of 15.5 months (range, 2.3-64.5), the median OS, PFS, and FFLP of the unmatched patients were 17.3 months, 11 months, and 19.6 months, respectively. After PS matching, there were no significant differences between the SBRT and CCRT groups in terms of the 1-year rates of OS (66.7% vs. 80%, p = 0.455), PFS (40.0% vs. 54.2%, p = 0.123), and FFLP (77.2% and 87.1%, p = 0.691). Our results suggest SBRT could be a feasible alternative to CCRT in treating patients with LAPC.
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Affiliation(s)
- Young Seob Shin
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.S.S.); (H.H.P.); (S.M.Y.); (J.J.); (J.H.K.)
| | - Hee Hyun Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.S.S.); (H.H.P.); (S.M.Y.); (J.J.); (J.H.K.)
| | - Jin-hong Park
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.S.S.); (H.H.P.); (S.M.Y.); (J.J.); (J.H.K.)
- Correspondence: ; Tel.: +82-2-3010-5616
| | - Dong-Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.-W.S.); (S.S.L.); (M.-H.K.); (S.K.L.); (D.H.P.); (T.J.S.); (D.O.)
| | - Sang Soo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.-W.S.); (S.S.L.); (M.-H.K.); (S.K.L.); (D.H.P.); (T.J.S.); (D.O.)
| | - Changhoon Yoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (C.Y.); (B.-Y.R.); (H.-M.C.); (K.-p.K.); (J.H.J.)
| | - Seonok Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea;
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.S.S.); (H.H.P.); (S.M.Y.); (J.J.); (J.H.K.)
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.S.S.); (H.H.P.); (S.M.Y.); (J.J.); (J.H.K.)
| | - Myung-Hwan Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.-W.S.); (S.S.L.); (M.-H.K.); (S.K.L.); (D.H.P.); (T.J.S.); (D.O.)
| | - Sung Koo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.-W.S.); (S.S.L.); (M.-H.K.); (S.K.L.); (D.H.P.); (T.J.S.); (D.O.)
| | - Do Hyun Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.-W.S.); (S.S.L.); (M.-H.K.); (S.K.L.); (D.H.P.); (T.J.S.); (D.O.)
| | - Tae Jun Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.-W.S.); (S.S.L.); (M.-H.K.); (S.K.L.); (D.H.P.); (T.J.S.); (D.O.)
| | - Dongwook Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (D.-W.S.); (S.S.L.); (M.-H.K.); (S.K.L.); (D.H.P.); (T.J.S.); (D.O.)
| | - Baek-Yeol Ryoo
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (C.Y.); (B.-Y.R.); (H.-M.C.); (K.-p.K.); (J.H.J.)
| | - Heung-Moon Chang
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (C.Y.); (B.-Y.R.); (H.-M.C.); (K.-p.K.); (J.H.J.)
| | - Kyu-pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (C.Y.); (B.-Y.R.); (H.-M.C.); (K.-p.K.); (J.H.J.)
| | - Jae Ho Jeong
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (C.Y.); (B.-Y.R.); (H.-M.C.); (K.-p.K.); (J.H.J.)
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Korea; (Y.S.S.); (H.H.P.); (S.M.Y.); (J.J.); (J.H.K.)
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Ermongkonchai T, Khor R, Muralidharan V, Tebbutt N, Lim K, Kutaiba N, Ng SP. Stereotactic radiotherapy and the potential role of magnetic resonance-guided adaptive techniques for pancreatic cancer. World J Gastroenterol 2022; 28:745-754. [PMID: 35317275 PMCID: PMC8891728 DOI: 10.3748/wjg.v28.i7.745] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/11/2021] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer is a malignancy with one of the poorest prognoses amongst all cancers. Patients with unresectable tumours either receive palliative care or undergo various chemoradiotherapy regimens. Conventional techniques are often associated with acute gastrointestinal toxicities, as adjacent critical structures such as the duodenum ultimately limits delivered doses. Stereotactic body radiotherapy (SBRT) is an advanced radiation technique that delivers highly ablative radiation split into several fractions, with a steep dose fall-off outside target volumes.
AIM To discuss the latest data on SBRT and whether there is a role for magnetic resonance-guided techniques in multimodal management of locally advanced, unresectable pancreatic cancer.
METHODS We conducted a search on multiple large databases to collate the latest records on radiotherapy techniques used to treat pancreatic cancer. Out of 1229 total records retrieved from our search, 36 studies were included in this review.
RESULTS Studies indicate that SBRT is associated with improved clinical efficacy and toxicity profiles compared to conventional radiotherapy techniques. Further dose escalation to the tumour with SBRT is limited by the poor soft-tissue visualisation of computed tomography imaging during radiation planning and treatment delivery. Magnetic resonance-guided techniques have been introduced to improve imaging quality, enabling treatment plan adaptation and re-optimisation before delivering each fraction.
CONCLUSION Therefore, SBRT may lead to improved survival outcomes and safer toxicity profiles compared to conventional techniques, and the addition of magnetic resonance-guided techniques potentially allows dose escalation and conversion of unresectable tumours to operable cases.
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Affiliation(s)
- Tai Ermongkonchai
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Niall Tebbutt
- Department of Medical Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Kelvin Lim
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Numan Kutaiba
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
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Laskar SG, Kakoti S. Modern Radiation Oncology: From IMRT to Particle Therapy—Present Status and the Days to Come. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1742446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractThere has been tremendous technological development in the field of radiation oncology, mainly during the last few decades. Parallel advancements in imaging and accelerator technologies have contributed significantly to the same. Present-day radiation therapy is aimed at precision, in terms of physical accuracy of both its planning and delivery. This has been made possible by improvements in defining the target (use of various radiological and functional imaging modalities), advanced radiotherapy planning methods (intensity-modulated radiation therapy and recent emergence of particle therapy), and robust verification techniques (image-guided radiation therapy). These developments have enabled delivery of adequate tumoricidal doses conforming to the target, thereby improving disease control with reduced normal tissue toxicity in a wide range of malignancies. Elucidation of molecular pathways determining radioresistance or systemic effects of radiotherapy and strategies for therapeutic manipulation of the same are also being explored. Overall, we look forward to ensuring basic radiotherapy access to all patients, and precision radiation therapy to appropriate candidates (triaged by disease anatomy or biology and associated cost-effectiveness).
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Affiliation(s)
- Sarbani Ghosh Laskar
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sangeeta Kakoti
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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30
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Anup A, Bhandare M, Chaudhari V, Krishnatry R, Shrikhande S, Ramaswamy A, Baheti A, Ramadwar M, Engineer R. Predictors of outcome in patients receiving stereotactic body radiation therapy for borderline resectable and locally advanced pancreatic cancers. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2022. [DOI: 10.5348/100098z04aa2022ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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31
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Daamen LA, de Mol van Otterloo SR, van Goor IWJM, Eijkelenkamp H, Erickson BA, Hall WA, Heerkens HD, Meijer GJ, Molenaar IQ, van Santvoort HC, Verkooijen HM, Intven MPW. Online adaptive MR-guided stereotactic radiotherapy for unresectable malignancies in the upper abdomen using a 1.5T MR-linac. Acta Oncol 2022; 61:111-115. [PMID: 34879792 DOI: 10.1080/0284186x.2021.2012593] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Introduction of online adaptive MR-guided radiotherapy enables stereotactic body radiation therapy (SBRT) of upper abdominal tumors. This study aimed to evaluate the feasibility of MR-guided SBRT on a 1.5 T MR-linac in patients with unresectable upper abdominal malignancies. MATERIAL AND METHODS Patients treated at the UMC Utrecht (April 2019 to December 2020) were identified in the prospective 'Multi-OutcoMe EvaluatioN of radiation Therapy Using the MR-linac' (MOMENTUM) study. Feasibility of treatment was arbitrarily defined as an on-table time interval of ≤60 min for >75% of delivered fractions and completion of >95% of fractions as scheduled, reflecting patient tolerability. Acute treatment-related toxicity was assessed at 3 months of follow-up and graded according to the National Cancer Institute Common Terminology Criteria of Adverse Events version 5.0. RESULTS Twenty-five consecutive patients with a median follow-up time of 8 (range 4-23) months were treated with 35 Gray (n = 4) and 40 Gray (n = 21) in five fractions over 2 weeks. For all fractions, contours were adapted based on the daily anatomy and delivered within 47 min/fraction (range 30-74). In 98/117 fractions (84%), adapted treatment was completed within 1 h. All patients received the scheduled irradiation dose as planned. No acute grade 3 toxicity or higher was reported. Treatment resulted in pain alleviation in 11/13 patients. DISCUSSION Online adaptive MR-guided SBRT on a 1.5 T MR-linac is feasible and well-tolerated in patients with unresectable upper abdominal malignancies. Dose escalation studies, followed by comparative studies, are needed to determine the optimal radiation dose for irradiation of upper abdominal malignancies.
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Affiliation(s)
- Lois A. Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | | | - Iris W. J. M. van Goor
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Beth A. Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hanne D. Heerkens
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Gert J. Meijer
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center & St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Helena M. Verkooijen
- Division of Imaging, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
| | - Martijn P. W. Intven
- Department of Radiation Oncology, UMC Utrecht Cancer Center, Utrecht University, Utrecht, The Netherlands
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Evolving pancreatic cancer treatment: From diagnosis to healthcare management. Crit Rev Oncol Hematol 2021; 169:103571. [PMID: 34923121 DOI: 10.1016/j.critrevonc.2021.103571] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/13/2021] [Indexed: 12/12/2022] Open
Abstract
The prognosis of pancreatic ductal adenocarcinoma is still the worst among solid tumors. In this review, a panel of experts addressed the main unanswered questions about the clinical management of this disease, with the aim of providing practical decision support for physicians. On the basis of the evidence available from the literature, the main topics concerning pancreatic cancer are discussed: the diagnosis, as the need for a pathological characterization and the role for germ-line and somatic molecular profiling; the therapeutic management of resectable disease, as the role of upfront surgery or neoadjuvant chemotherapy, the post-operative restaging and the optimal timing foradjuvant chemotherapy, the management of the borderline resectable and locally advanced disease; the metastatic disease and the role of surgery for the management of patients with isolated metastasis and the use of biomarkers of metastatic potential; the role of supportive care and the healthcare management of pancreatic ductal adenocarcinoma.
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Spiliopoulos S, Zurlo MT, Casella A, Laera L, Surico G, Surgo A, Fiorentino A, de'Angelis N, Calbi R, Memeo R, Inchingolo R. Current status of non-surgical treatment of locally advanced pancreatic cancer. World J Gastrointest Oncol 2021; 13:2064-2075. [PMID: 35070042 PMCID: PMC8713317 DOI: 10.4251/wjgo.v13.i12.2064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/28/2021] [Accepted: 10/25/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the 7th leading cause of death due to cancer in industrialized countries and the 11th most common cancer globally, with 458918 new cases (2.5% of all cancers) and 432242 deaths (4.5% of all cancer deaths) in 2018. Unfortunately, 80% to 90% of the patients present with unresectable disease, and the reported 5-year survival rate range between 10% and 25%, even after successful resection with tumor-free margins. Systemic chemotherapy, radiotherapy, and minimally invasive image-guided procedures that have emerged over the past years, are used for the management of non-operable PC. This review focuses on currently available non-surgical options of locally advanced pancreatic cancer.
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Affiliation(s)
- Stavros Spiliopoulos
- 2nd Radiology Department, Interventional Radiology Unit, National and Kapodistrian University of Athens, Athens 12461, Greece
| | - Maria Teresa Zurlo
- Interventional Radiology Unit, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Annachiara Casella
- Unit of Hepato-Pancreatic-Biliary Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Letizia Laera
- Department of Oncology, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti 70021, Italy
| | - Giammarco Surico
- Department of Oncology, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti 70021, Italy
| | - Alessia Surgo
- Department of Radiation Oncology, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Alba Fiorentino
- Department of Radiation Oncology, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Roberto Calbi
- Department of Radiology, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti 70021, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreatic-Biliary Surgery, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, “F. Miulli” Regional General Hospital, Acquaviva delle Fonti 70021, Italy
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34
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Mills BN, Qiu H, Drage MG, Chen C, Mathew JS, Garrett-Larsen J, Ye J, Uccello TP, Murphy JD, Belt BA, Lord EM, Katz AW, Linehan DC, Gerber SA. Modulation of the Human Pancreatic Ductal Adenocarcinoma Immune Microenvironment by Stereotactic Body Radiotherapy. Clin Cancer Res 2021; 28:150-162. [PMID: 34862242 DOI: 10.1158/1078-0432.ccr-21-2495] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/23/2021] [Accepted: 10/13/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) is an emerging treatment modality for pancreatic ductal adenocarcinoma (PDAC), which can effectively prime cytotoxic T cells by inducing immunogenic tumor cell death in preclinical models. SBRT effects on human PDAC have yet to be thoroughly investigated; therefore, this study aimed to characterize immunomodulation in the human PDAC tumor microenvironment following therapy. EXPERIMENTAL DESIGN Tumor samples were obtained from patients with resectable PDAC. Radiotherapy was delivered a median of 7 days prior to surgical resection, and sections were analyzed by multiplex IHC (mIHC), RNA sequencing, and T-cell receptor sequencing (TCR-seq). RESULTS Analysis of SBRT-treated tumor tissue indicated reduced tumor cell density and increased immunogenic cell death relative to untreated controls. Radiotherapy promoted collagen deposition; however, vasculature was unaffected and spatial analyses lacked evidence of T-cell sequestration. Conversely, SBRT resulted in fewer tertiary lymphoid structures and failed to lessen or reprogram abundant immune suppressor populations. Higher percentages of PD-1+ T cells were observed following SBRT, and a subset of tumors displayed more clonal T-cell repertoires. CONCLUSIONS These findings suggest that SBRT augmentation of antitumor immunogenicity may be dampened by an overabundance of refractory immunosuppressive populations, and support the continued development of SBRT/immunotherapy combination for human PDAC.
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Affiliation(s)
- Bradley N Mills
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Haoming Qiu
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.,Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Michael G Drage
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Chunmo Chen
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Jocelyn S Mathew
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jesse Garrett-Larsen
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jian Ye
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Taylor P Uccello
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
| | - Joseph D Murphy
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
| | - Brian A Belt
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Edith M Lord
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.,Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
| | - Alan W Katz
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.,Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, New York.,Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Scott A Gerber
- Department of Surgery, University of Rochester Medical Center, Rochester, New York. .,Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.,Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York
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35
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Jolissaint JS, Reyngold M, Bassmann J, Seier KP, Gönen M, Varghese AM, Yu KH, Park W, O’Reilly EM, Balachandran VP, D’Angelica MI, Drebin JA, Kingham TP, Soares KC, Jarnagin WR, Crane CH, Wei AC. Local Control and Survival After Induction Chemotherapy and Ablative Radiation Versus Resection for Pancreatic Ductal Adenocarcinoma With Vascular Involvement. Ann Surg 2021; 274:894-901. [PMID: 34269717 PMCID: PMC8599622 DOI: 10.1097/sla.0000000000005080] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We sought to compare overall survival (OS) and disease control for patients with localized pancreatic ductal adenocarcinoma (PDAC) treated with ablative dose radiotherapy (A-RT) versus resection. SUMMARY BACKGROUND DATA Locoregional treatment for PDAC includes resection when possible or palliative RT. A-RT may offer durable tumor control and encouraging survival. METHODS This was a single-institution retrospective analysis of patients with PDAC treated with induction chemotherapy followed by A-RT [≥98 Gy biologically effective dose (BED) using 15-25 fractions in 3-4.5 Gy/fraction] or pancreatectomy. RESULTS One hundred and four patients received A-RT (49.8%) and 105 (50.2%) underwent resection. Patients receiving A-RT had larger median tumor size after induction chemotherapy [3.2 cm (undetectable-10.9) vs 2.6 cm (undetectable-10.7), P < 0.001], and were more likely to have celiac or hepatic artery encasement (48.1% vs 11.4%, P <0.001), or superior mesenteric artery encasement (43.3% vs 9.5%, P < 0.001); however, there was no difference in the degree of SMV/PV involvement (P = 0.123). There was no difference in locoregional recurrence/progression at 18-months between A-RT and resection; cumulative incidence was 16% [(95% confidence interval (CI) 10%-24%] versus 21% (95% CI 14%-30%), respectively (P= 0.252). However, patients receiving A-RT had a 19% higher 18-month cumulative incidence of distant recurrence/progression [58% (95% CI 48%-67%) vs 30% (95% CI 30%-49%), P= 0.004]. Median OS from completion of chemotherapy was 20.1 months for A-RT patients (95% CI 16.4-23.1 months) versus 32.9 months (95% CI 29.7-42.3 months) for resected patients (P < 0.001). CONCLUSION Ablative radiation is a promising new treatment option for PDAC, offering locoregional disease control similar to that associated with resection and encouraging survival.
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Affiliation(s)
- Joshua S. Jolissaint
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jared Bassmann
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth P. Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gönen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anna M. Varghese
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth H. Yu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Wungki Park
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eileen M. O’Reilly
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kevin C. Soares
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Christopher H. Crane
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alice C. Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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36
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Barros AG, Pulido CF, Machado M, Brito MJ, Couto N, Sousa O, Melo SA, Mansinho H. Treatment optimization of locally advanced and metastatic pancreatic cancer (Review). Int J Oncol 2021; 59:110. [PMID: 34859257 PMCID: PMC8651228 DOI: 10.3892/ijo.2021.5290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignant tumor types, being the sixth leading cause of mortality worldwide and the fourth in Europe. Globally, it has a mortality/incidence ratio of 98%, and the 5‑year survival rate in Europe is only 3%. Although risk factors, such as obesity, diabetes mellitus, smoking, alcohol consumption and genetic factors, have been identified, the causes of PDAC remain elusive. Additionally, the only curative treatment for PDAC is surgery with negative margins. However, upon diagnosis, ~30% of the patients already present with locally advanced disease. In these cases, a multidisciplinary approach is required to improve disease‑related symptoms and prolong patient survival. In the present article, a comprehensive review of PDAC epidemiology, physiology and treatment is provided. Moreover, guidelines on patient treatment are suggested. Among the different available therapeutic options for the treatment of advanced PDAC, results are modest, most likely due to the complexity of the disease, and so the prognostic remains poor. Molecular approaches based on multi‑omics research are promising and will contribute to groundbreaking personalized medicine. Thus, economic investment that promotes research of pancreatic cancer will be critical to the development of more efficient diagnostic and treatment strategies.
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Affiliation(s)
- Anabela G. Barros
- Department of Medical Oncology, University Hospital of Coimbra, 3004-561 Coimbra, Portugal
| | - Catarina F. Pulido
- Department of Medical Oncology, Luz Lisbon Hospital, 1500-650 Lisbon, Portugal
| | - Manuela Machado
- Department of Medical Oncology, Entre o Douro e Vouga Hospital Center (CHEDV), 4520-211 Santa Maria da Feira, Portugal
| | - Maria José Brito
- Pathologic Anatomy Department, Garcia de Orta Hospital, 2805-267 Almada, Portugal
| | - Nuno Couto
- Digestive Unit, Champalimaud Clinical Centre, 4200-135 Porto, Portugal
- Champalimaud Research Centre, 1400-038 Lisbon, 4200-135 Porto, Portugal
| | - Olga Sousa
- Radiotherapy Department, Portuguese Institute of Oncology, 4200-072 Porto, 4200-135 Porto, Portugal
| | - Sónia A. Melo
- i3S-Institute for Research and Innovation in Health of University of Porto, 4200-135 Porto, Portugal
- IPATIMUP-Institute of Molecular Pathology and Immunology of University of Porto, 4200-135 Porto, Portugal
- Faculty of Medicine, University of Porto, 4200-319 Porto, Portugal
| | - Hélder Mansinho
- Hemato-Oncology Department, Garcia de Orta Hospital, 2805-267 Almada, Portugal
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37
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Bouchart C, Engelholm JL, Closset J, Navez J, Loi P, Gökburun Y, De Grez T, Mans L, Hendlisz A, Bali MA, Eisendrath P, Van Gestel D, Hein M, Moretti L, Van Laethem JL. Isotoxic high-dose stereotactic body radiotherapy integrated in a total multimodal neoadjuvant strategy for the treatment of localized pancreatic ductal adenocarcinoma. Ther Adv Med Oncol 2021; 13:17588359211045860. [PMID: 34691244 PMCID: PMC8529314 DOI: 10.1177/17588359211045860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/25/2021] [Indexed: 01/06/2023] Open
Abstract
Background Our aim was to evaluate the feasibility and safety of isotoxic high-dose (iHD) stereotactic body radiation therapy (SBRT) in a total neoadjuvant sequence for the treatment of localized pancreatic adenocarcinoma. Materials and methods Biopsy-proven borderline resectable/locally advanced pancreatic cancer (BR/LAPC) patients were included in this observational prospective analysis from August 2017 to April 2020 without excluding tumours showing a radiological direct gastrointestinal (GI) invasion. An induction chemotherapy by modified fluorouracil, irinotecan and oxaliplatin was performed for a median of six cycles. In case of non-progression, an isotoxic high-dose stereotactic body radiotherapy (iHD-SBRT) was delivered in 5 fractions followed by a surgical exploration. The primary endpoint was acute/late gastrointestinal grade ⩾3 toxicity. Secondary endpoints were overall survival (OS), progression-free survival (PFS) and local control (LC). Results A total of 39 consecutive patients (21 BR and 18 LAPC) were included: 34 patients (87.2%, 18 BR and 16 LAPC) completed the planned neoadjuvant sequence. After iHD-SBRT, 19 patients [55.9% overall, 13/18 BR (72.2%) and 6/16 LAPC (37.5%)] underwent an oncological resection among the 25 patients surgically explored (73.5%). The median follow up was 18.2 months. The rates of acute and late GI grade 3 toxicity were, respectively, 2.9% and 4.2%. The median OS and PFS from diagnosis were, respectively, 24.5 and 15.6 months. The resected patients had improved median OS and PFS in comparison with the non-resected patients (OS: 32.3 versus 18.2 months, p = 0.02; PFS: 24.1 versus 7.1 months, p < 0.001). There was no survival difference between the BR and LAPC patients. The 1-year LC from SBRT was 74.1% and the median locoregional PFS was not reached for both BR and LAPC patients. Conclusions iHD-SBRT displays an excellent toxicity profile, also for potentially high-risk patients with radiological direct GI invasion at diagnosis and can be easily integrated in a total neoadjuvant strategy. The oncological outcomes are promising and emphasise the need for further exploration of iHD-SBRT in phase II/III trials.
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Affiliation(s)
- Christelle Bouchart
- Department of Radiation-Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Boulevard de Waterloo, 121, Brussels 1000, Belgium
| | - Jean-Luc Engelholm
- Department of Radiology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Department of Hepato-Biliary-Pancreatic Surgery, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Julie Navez
- Department of Hepato-Biliary-Pancreatic Surgery, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Patrizia Loi
- Department of Hepato-Biliary-Pancreatic Surgery, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Yeter Gökburun
- Department of Gastroenterology, CHR Namur, Namur, Belgium
| | | | - Laura Mans
- Department of Gastroenterology, Hepatology and Digestive Oncology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Hendlisz
- Department of Medical Oncology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Maria Antonietta Bali
- Department of Radiology, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology, CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Gestel
- Department of Radiation-Oncology, Institut Jules Bordet,Université Libre de Bruxelles, Brussels, Belgium
| | - Matthieu Hein
- Sleep Laboratory, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Luigi Moretti
- Department of Radiation-Oncology, Institut Jules Bordet,Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology, Hepatology and Digestive Oncology, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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38
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Liu P, Gao XS, Wang Z, Li X, Xi C, Jia C, Xie M, Lyu F, Ding X. Investigate the Dosimetric and Potential Clinical Benefits Utilizing Stereotactic Body Radiation Therapy With Simultaneous Integrated Boost Technique for Locally Advanced Pancreatic Cancer: A Comparison Between Photon and Proton Beam Therapy. Front Oncol 2021; 11:747532. [PMID: 34631584 PMCID: PMC8493097 DOI: 10.3389/fonc.2021.747532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose To investigate the potential clinical benefits of using stereotactic body radiation therapy (SBRT) with simultaneous integrated boost (SIB) technique for locally advanced pancreatic cancer (LAPC) among different treatment modalities and planning strategies, including photon and proton. Method A total of 19 patients were retrospectively selected in this study: 13 cases with the tumor located in the head of the pancreas and 6 cases with the tumor in the body of the pancreas. SBRT-SIB plans were generated using volumetric modulated arc therapy (VMAT), two-field Intensity Modulated Proton Therapy (IMPT), and three-field IMPT. The IMPT used the robust optimization parameters of ± 3.5% range and 5-mm setup uncertainties. Root-mean-square deviation dose (RMSD) volume histograms were used to evaluate the target coverage robustness quantitatively. Dosimetric metrics based on the dose-volume histogram (DVH), homogeneity index (HI), and normal tissue complication probability (NTCP) were analyzed to evaluate the potential clinical benefits among different planning groups. Results With a similar CTV and SIB coverage, two-field IMPT provided a lower maximum dose for the stomach (median: 18.6GyE, p<0.05) and duodenum (median: 32.62GyE, p<0.05) when the target was located in the head of the pancreas compared to VMAT and three-field IMPT. The risks of gastric bleed (3.42%) and grade ≥ 3 GI toxicity (4.55%) were also decreased. However, for the target in the body of the pancreas, VMAT showed a lower maximum dose for the stomach (median 30.93GyE, p<0.05) and toxicity of gastric bleed (median: 8.67%, p<0.05) compared to two-field IMPT and three-field IMPT, while other maximum doses and NTCPs were similar. The RMSD volume histogram (RVH) analysis shows that three-field IMPT provided better robustness for targets but not for OARs. Instead, three-field IMPT increased the Dmean of organs such as the stomach, duodenum, and intestine. Conclusion The results indicated that the tumor locations could play a critical role in determining clinical benefits among different treatment modalities. Two-field IMPT could be a better option for LAPC patients whose tumors are located in the head of the pancreas. It provides lower severe toxicity for the stomach and duodenum. Nevertheless, VMAT is preferred for the body with better protection for the possibility of gastric bleed.
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Affiliation(s)
- Peilin Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Zishen Wang
- Department of Radiation Oncology, Hebei Yizhou Tumor Hospital, Zhuozhou, China
| | - Xiaomei Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Cao Xi
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Chenghao Jia
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Mu Xie
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Feng Lyu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Proton Beam Therapy Center, Royal Oak, MI, United States
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Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based, multi-disciplinary diagnostic and therapeutic approaches. Pancreatology 2021; 21:1326-1341. [PMID: 34148794 DOI: 10.1016/j.pan.2021.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer. This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.
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Wang G, Wang H, Zhuang H, Yang R. An Investigation of Non-Coplanar Volumetric Modulated Radiation Therapy for Locally Advanced Unresectable Pancreatic Cancer Using a Trajectory Optimization Method. Front Oncol 2021; 11:717634. [PMID: 34604054 PMCID: PMC8485751 DOI: 10.3389/fonc.2021.717634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/26/2021] [Indexed: 12/24/2022] Open
Abstract
PURPOSE This study was conducted in order to develop a trajectory optimization algorithm for non-coplanar volumetric modulated arc therapy (VMAT) and investigate the potential of organs at risk (OARs) sparing in locally advanced pancreatic cancer patients using non-coplanar VMAT. METHODS AND MATERIALS Firstly, a cost map that represents the ray-OAR voxel intersections at each source position was generated using a ray-tracing algorithm. A graph search algorithm was then used to determine the least-cost path from the cost map. Lastly, full arcs or partial arcs were selected based on the least-cost path to generate the non-coplanar VMAT (ncVMAT) trajectories. Clinical coplanar VMAT (coVMAT) plans for 11 patients diagnosed with locally advanced unresectable pancreatic cancer (LAPC) receiving 45 to 70 Gy in 25 fractions were replanned using non-coplanar VMAT trajectories. Both coplanar and non-coplanar plans were normalized to cover 95% of the PTV45 Gy volume with a prescription dose of 45 Gy. The conformity index (CI), homogeneity index (HI), PTV coverage, and dose to the OARs were compared between coVMAT and ncVMAT plans. RESULTS With ncVMAT, the mean coverage of PTV50 Gy, PTV54 Gy, PTV60 Gy, and PTV70 Gy increased significantly. The mean conformity index of PTV45 Gy, PTV54 Gy, and PTV70 Gy was also improved in the ncVMAT plans. Compared with coVMAT plans, the ncVMAT plans resulted in significantly lower doses to the spinal cord, bilateral kidneys, stomach, and duodenum. The maximum dose to the spinal cord decreased by 6.11%. The mean dose to the left and right kidneys decreased by an average of 5.52% and 11.71%, respectively. The D max, D mean, and D 15% of the stomach were reduced by an average of 7.45%, 15.82%, and 16.79%, separately. The D 15% and D mean of the duodenum decreased 6.38% and 5.64%, respectively. CONCLUSION A trajectory optimization algorithm was developed for non-coplanar VMAT. Compared with conventional coplanar VMAT, non-coplanar VMAT resulted in improved coverage and conformity to the targets. The sparing of OARs was significantly improved in non-coplanar VMAT compared with coVMAT plans for locally advanced pancreatic cancer.
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Affiliation(s)
| | | | | | - Ruijie Yang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
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Passardi A, Rapposelli IG, Scarpi E, Sullo FG, Bartolini G, Neri E, Ghigi G, Tontini L, Ercolani G, Monti M, Ruscelli S, Matteucci L, Valgiusti M, Frassineti GL, Romeo A. Multimodal Treatment with GEMOX Plus Helical Tomotherapy in Unresectable Locally Advanced Pancreatic Cancer: A Pooled Analysis of Two Phase 2 Studies. Biomolecules 2021; 11:biom11081200. [PMID: 34439866 PMCID: PMC8393939 DOI: 10.3390/biom11081200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/29/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022] Open
Abstract
In locally advanced pancreatic cancer (LAPC), the combination of chemotherapy and radiotherapy is a widely used treatment option. We performed a pooled analysis, including an exploratory analysis for prognostic and predictive factors, of two phase 2 trials including 73 patients with LAPC, treated with gemcitabine and oxaliplatin (GEMOX) and hypofractionated tomotherapy. With a median follow-up of 36 months (range 1–65), median progression-free (PFS) and overall survival (OS) were 10.2 (95% confidence interval [CI] 7.8–13.2) and 14.3 (95% CI 12.0–18.1) months, respectively. The overall resectability rate was 23.3% (95% CI 13.6–33.0), and the R0 resection rate was 13.7% (95% CI 5.8–21.6). In the multivariate analysis, ECOG performance status (PS) 0 and low levels of CA 19–9 were associated with improved OS and PFS. Concerning OS, log(CA19–9) resulted in a hazard ratio (HR) of 1.20 (95% CI 1.02–1.42), p = 0.027. For ECOG PS 0, HR was 1.00; for PS 1, HR was 2.69 (95% CI 1.46–4.96); for PS 2, HR was 4.18 (95% CI 0.90–19.46); p = 0.003. Low CA19–9 levels were also predictive for resection, with an odds ratio of 0.71 (95% CI 0.52–0.97), p = 0.034. In conclusion, GEMOX and hypofractionated radiotherapy is a treatment option in LAPC. Further studies are needed to identify differences in tumor biology, which may help to predict resectability and prognosis.
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Affiliation(s)
- Alessandro Passardi
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Ilario Giovanni Rapposelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
- Correspondence: ; Tel.: +39-0543-739100
| | - Emanuela Scarpi
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy;
| | - Francesco Giulio Sullo
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giulia Bartolini
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Elisa Neri
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giulia Ghigi
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Luca Tontini
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
| | - Giorgio Ercolani
- General and Oncologic Surgery Unit, Morgagni-Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy;
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Manlio Monti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Silvia Ruscelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Laura Matteucci
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Martina Valgiusti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (A.P.); (F.G.S.); (G.B.); (M.M.); (S.R.); (L.M.); (M.V.); (G.L.F.)
| | - Antonino Romeo
- Radiotherapy Unit, IRCCS Istituto Romagnolo Per lo Studio dei Tumori “Dino Amadori”—IRST, 47014 Meldola, Italy; (E.N.); (G.G.); (L.T.); (A.R.)
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Courtney PT, Paravati AJ, Atwood TF, Raja N, Zimmerman CT, Fanta PT, Lowy AM, Simpson DR, Xu R, Murphy JD. Phase I Trial of Stereotactic Body Radiation Therapy Dose Escalation in Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2021; 110:1003-1012. [PMID: 33571625 DOI: 10.1016/j.ijrobp.2021.02.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/22/2020] [Accepted: 02/03/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) has demonstrated encouraging local tumor control rates in the treatment of pancreatic cancer, yet we lack prospective clinical trials evaluating dose-escalation strategies among patients treated with 5-fraction SBRT. This phase 1 dose-escalation trial was conducted to determine the maximum tolerated dose of SBRT in patients with pancreatic cancer. METHODS AND MATERIALS Thirty patients with pancreatic cancer were enrolled and treated with 40, 45, or 50 Gy SBRT in 5 fractions with doses determined using a time-to-event continual reassessment method trial design. Systemic therapy was permitted before and after SBRT, but not mandated by the study protocol. Toxicity was the primary study endpoint, and any grade ≥3 acute or late toxicity potentially attributable to SBRT was considered a dose-limiting toxicity. Secondary endpoints included local progression, distant progression, and overall survival. RESULTS The median follow up from SBRT was 8.9 months (range, 1.7-62.6 months). Nineteen patients (63%) had locally advanced disease, 3 patients (10%) had metastatic disease, and 8 patients (27%) had medically unresectable disease. Three patients (10%) received 40 Gy, 16 patients (53%) received 45 Gy, and 11 patients (37%) received 50 Gy. Seven patients (23%) experienced grade ≤2 acute toxicity, and 2 patients (6.7%) experienced grade 4 to 5 late toxicity, both of which occurred in the 45 Gy group. Median survival time was 17.1 months from the time of diagnosis and 9.8 months from SBRT. The 1-year cumulative incidence of local progression was 14.2% (95% confidence interval, 4.2%-30%). CONCLUSIONS This dose-escalation trial evaluated high-dose SBRT delivered in 5 fractions, and overall demonstrated favorable local control and survival, but was associated with nontrivial rates of severe late gastrointestinal toxicity potentially attributable to radiation. Further prospective studies are needed to define the safety and efficacy of high-dose SBRT in patients with pancreatic cancer.
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Affiliation(s)
- P Travis Courtney
- University of California San Diego School of Medicine, La Jolla, California; Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Anthony J Paravati
- Kettering Cancer Care Department of Radiation Oncology, Kettering Health Network, Kettering, Ohio
| | - Todd F Atwood
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Nandita Raja
- Department of Hematology and Oncology, Kaiser Permanente Southern California, San Diego, California
| | - Collin T Zimmerman
- Department of Hematology and Oncology, Kaiser Permanente Southern California, San Diego, California
| | - Paul T Fanta
- Center for Personalized Cancer Therapy and Division of Hematology and Oncology, Department of Medicine, University of California San Diego Moores Cancer Center, La Jolla, California
| | - Andrew M Lowy
- Department of Surgery, University of California San Diego Moores Cancer Center, La Jolla, California
| | - Daniel R Simpson
- University of California San Diego School of Medicine, La Jolla, California; Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California
| | - Ronghui Xu
- Department of Family Medicine and Public Health and Department of Mathematics, University of California San Diego, La Jolla, California
| | - James D Murphy
- University of California San Diego School of Medicine, La Jolla, California; Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California.
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Kinh Do R, Reyngold M, Paudyal R, Oh JH, Konar AS, LoCastro E, Goodman KA, Shukla-Dave A. Diffusion-Weighted and Dynamic Contrast-Enhanced MRI Derived Imaging Metrics for Stereotactic Body Radiotherapy of Pancreatic Ductal Adenocarcinoma: Preliminary Findings. ACTA ACUST UNITED AC 2021; 6:261-271. [PMID: 32548304 PMCID: PMC7289241 DOI: 10.18383/j.tom.2020.00015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
We aimed to assess longitudinal changes in quantitative imaging metric values obtained from diffusion-weighted (DW-) and dynamic contrast-enhanced magnetic resonance imaging (DCE)-MRI at pre-treatment (TX[0]), immediately after the first fraction of stereotactic body radiotherapy (D1-TX[1]), and 6 weeks post-TX (Post-TX[2]) in patients with pancreatic ductal adenocarcinoma. Ten enrolled patients (n = 10) underwent DW- and DCE-MRI examinations on a 3.0 T scanner. The apparent diffusion coefficient, ADC (mm2/s), was derived from DW imaging data using a monoexponential model. The tissue relaxation rate, R 1t, time-course data were fitted with a shutter-speed model, which provides estimates of the volume transfer constant, K trans (min-1), extravascular extracellular volume fraction, ve , and mean lifetime of intracellular water protons, τ i (seconds). Wilcoxon rank-sum test compared the mean values, standard deviation, skewness, kurtosis, and relative percentage (r, %) changes (Δ) in ADC, K trans, ve , and τ i values between the magnetic resonance examinations. rADCΔ2-0 values were significantly greater than rADCΔ1-0 values (P = .009). rK trans Δ2-0 values were significantly lower than rK trans Δ1-0 values (P = .048). rve Δ2-1 and rveΔ2-0 values were significantly different (P = .016). rτ i Δ2-1 values were significantly lower than rτ i Δ2-0 values (P = .008). For group comparison, the pre-TX mean and kurtosis of ADC (P = .18 and P = .14), skewness and kurtosis of K trans values (P = .14 for both) showed a leaning toward significant difference between patients who experienced local control (n = 2) and failed early (n = 4). DW- and DCE-MRI-derived quantitative metrics could be useful biomarkers to evaluate longitudinal changes to stereotactic body radiotherapy in patients with pancreatic ductal adenocarcinoma.
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Affiliation(s)
| | | | - Ramesh Paudyal
- Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Jung Hun Oh
- Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | | | - Eve LoCastro
- Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Karyn A Goodman
- Tisch Cancer Institute at Mount Sinai Hospital, New York, NY
| | - Amita Shukla-Dave
- Departments of Radiology.,Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY; and
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Janssen QP, van Dam JL, Kivits IG, Besselink MG, van Eijck CHJ, Homs MYV, Nuyttens JJME, Qi H, van Santvoort HJ, Wei AC, de Wilde RF, Wilmink JW, van Tienhoven G, Groot Koerkamp B. Added Value of Radiotherapy Following Neoadjuvant FOLFIRINOX for Resectable and Borderline Resectable Pancreatic Cancer: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2021; 28:8297-8308. [PMID: 34142290 PMCID: PMC8591030 DOI: 10.1245/s10434-021-10276-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/09/2021] [Indexed: 12/30/2022]
Abstract
Background The added value of radiotherapy following neoadjuvant FOLFIRINOX chemotherapy in patients with resectable or borderline resectable pancreatic cancer ((B)RPC) is unclear. The objective of this meta-analysis was to compare outcomes of patients who received neoadjuvant FOLFIRINOX alone or combined with radiotherapy. Methods A systematic literature search was performed in Embase, Medline (ovidSP), Web of Science, Scopus, Cochrane, and Google Scholar. The primary endpoint was pooled median overall survival (OS). Secondary endpoints included resection rate, R0 resection rate, and other pathologic outcomes. Results We included 512 patients with (B)RPC from 15 studies, of which 7 were prospective nonrandomized studies. In total, 351 patients (68.6%) were treated with FOLFIRINOX alone (8 studies) and 161 patients (31.4%) were treated with FOLFIRINOX and radiotherapy (7 studies). The pooled estimated median OS was 21.6 months (range 18.4–34.0 months) for FOLFIRINOX alone and 22.4 months (range 11.0–37.7 months) for FOLFIRINOX with radiotherapy. The pooled resection rate was similar (71.9% vs. 63.1%, p = 0.43) and the pooled R0 resection rate was higher for FOLFIRINOX with radiotherapy (88.0% vs. 97.6%, p = 0.045). Other pathological outcomes (ypN0, pathologic complete response, perineural invasion) were comparable. Conclusions In this meta-analysis, radiotherapy following neoadjuvant FOLFIRINOX was associated with an improved R0 resection rate as compared with neoadjuvant FOLFIRINOX alone, but a difference in survival could not be demonstrated. Randomized trials are needed to determine the added value of radiotherapy following neoadjuvant FOLFIRINOX in patients with (B)PRC. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-10276-8.
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Affiliation(s)
- Quisette P Janssen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jacob L van Dam
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Isabelle G Kivits
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marjolein Y V Homs
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hongchao Qi
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hjalmar J van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center Utrecht, Nieuwegein, The Netherlands
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Geertjan van Tienhoven
- Department of Radiation Oncology, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
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Rossi G, Simoni N, Paiella S, Rossi R, Venezia M, Micera R, Malleo G, Salvia R, Giuliani T, Di Gioia A, Auriemma A, Milella M, Guariglia S, Cavedon C, Bassi C, Mazzarotto R. Risk Adapted Ablative Radiotherapy After Intensive Chemotherapy for Locally Advanced Pancreatic Cancer. Front Oncol 2021; 11:662205. [PMID: 33959509 PMCID: PMC8093383 DOI: 10.3389/fonc.2021.662205] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/16/2021] [Indexed: 01/05/2023] Open
Abstract
Background and Objective To assess the efficacy of a Risk-Adapted Ablative Radiotherapy (RAdAR) approach, after intensive induction chemotherapy, in patients with locally advanced pancreatic cancer (LAPC). Material and Methods Patients with LAPC who received RAdAR following induction chemotherapy from January 2017 to December 2019 were included in this observational study. The RAdAR approach consisted of an anatomy- and simultaneous integrated boost (SIB)-based dose prescription strategy. RAdAR was delivered with stereotactic ablative radiation therapy (SAbR), administering 30 Gy in 5 fractions to the tumor volume (PTVt) and 50 Gy SIB (BED10 100 Gy) to the vascular involvement, or with (hypo-)fractionated ablative radiotherapy (HART) prescribing 50.4 Gy in 28 fractions to the PTVt, with a vascular SIB of 78.4 Gy (BED10 100 Gy). Primary end points were freedom from local progression (FFLP), overall survival (OS), and progression-free survival (PFS). Results Sixty-four LAPC patients were included. Induction chemotherapy consisted of gemcitabine/nab-paclitaxel in 60.9% and FOLFIRINOX in 39.1% of cases. SAbR was used in 52 (81.2%) patients, and HART in 12 (18.8%). After RAdAR, surgery was performed in 17 (26.6%) patients. Median follow-up was 16.1 months. Overall local control (LC) rate was 78.1%, with no difference between resected and non-resected patients (2-year FFLP 75.3% vs 56.4%; p = 0.112). Median OS and PFS were 29.7 months and 8.7 months, respectively, for the entire cohort. Resected patients had a better median OS (not reached versus 26.1 months; p = 0.0001) and PFS (19 versus 5.6 months; p < 0.0001) compared to non-resected patients. In non-resected patients, no significant difference was found between SAbR and HART for median FFLP (28.1 versus 18.5 months; p = 0.614), OS (27.4 versus 25.3 months; p = 0.624), and PFS (5.7 versus 4.3 months; p = 0.486). One patient (1.6%) experienced acute grade 4 gastro-intestinal bleeding. No other acute or late grade ≥ 3 toxicities were observed. Conclusions The RAdAR approach, following intensive induction chemotherapy, is an effective radiation treatment strategy for selected LAPC patients, representing a promising therapeutic option in a multimodality treatment regimen.
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Affiliation(s)
- Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Martina Venezia
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Renato Micera
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Giuliani
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Anthony Di Gioia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Auriemma
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Michele Milella
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
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Adjuvant chemotherapy versus observation following neoadjuvant therapy and surgery for resectable stages I–II pancreatic cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021; 21:383-392. [DOI: 10.1017/s1460396921000194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Aim:
This National Cancer Database (NCDB) analysis was performed to evaluate the outcomes of adjuvant chemotherapy (AC) versus observation for resected pancreatic adenocarcinoma treated with neoadjuvant therapy (NT).
Materials and methods:
The NCDB was queried for primary stages I–II cT1-3N0-1M0 resected pancreatic adenocarcinoma treated with NT (2004–2015). Baseline patient, tumour and treatment characteristics were extracted. The primary end point was overall survival (OS). With a 6-month conditional landmark, Kaplan–Meier analysis, multivariable Cox proportional hazards method and 1:1 propensity score matching was used to analyse the data.
Results:
A total of 1,737 eligible patients were identified, of which 1,247 underwent post-operative observation compared to 490 with AC. The overall median follow-up was 34·7 months. The addition of AC showed improved survival on the multivariate analysis (HR 0·78, p < 0·001). AC remained statistically significant for improved OS, with a median OS of 26·3 months versus 22·3 months and 2-year OS of 63·9% versus 52·9% for the observation cohort (p < 0·001). Treatment interaction analysis showed OS benefit of AC for patients with smaller tumours.
Findings:
Our findings suggest a survival benefit for AC compared to observation following NT and surgery for resectable pancreatic adenocarcinoma, especially in patients with smaller tumours.
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Ghaly M, Gogineni E, Herman J, Saif MW. New Potential Options for SBRT in Pancreatic Cancer. CANCER MEDICINE JOURNAL 2021; 4:41-50. [PMID: 34355218 PMCID: PMC8336074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Stereotactic body radiotherapy (SBRT) is an emerging treatment option for patients with pancreatic cancer, as it can provide a therapeutic benefit with significant advantages for patients' quality of life over standard conventional chemoradiation (CRT). The objective of this review is to present alternative clinical settings in which SBRT may benefit patients with pancreatic cancer. These include palliation of pain, elderly patients who are not surgical candidates, local therapy in oligometastatic cases and salvaging local failures after surgery or external beam radiation. We will review these individually and provide supporting literature for each.
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Affiliation(s)
- Maged Ghaly
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Emile Gogineni
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Joseph Herman
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Muhammad W Saif
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
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Buss EJ, Kachnic LA, Horowitz DP. Radiotherapy for locally advanced pancreatic ductal adenocarcinoma. Semin Oncol 2021; 48:106-110. [PMID: 33771355 DOI: 10.1053/j.seminoncol.2021.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 01/20/2023]
Abstract
Locally advanced, unresectable pancreatic ductal adenocarcinoma has a poor prognosis with a median overall survival of 10-16 months. It is defined by tumor involvement of neighboring blood vessels that precludes resection. Standard doses of conventionally fractionated radiation have had little effect on overall survival in this setting, although they are associated with improved progression-free survival and time off chemotherapy. Evolving radiotherapy techniques have allowed for higher, ablative doses of radiotherapy to target tumor while also respecting normal tissue constraints of neighboring radiosensitive structures in the gastrointestinal tract. Moreover, advancements in image guidance, organ motion management, and the use of adaptive planning have enabled safe delivery of higher, ablative doses of radiation. This has resulted in improved survival. This review will summarize the expanding role of radiotherapy in the management of locally advanced, unresectable pancreatic cancer.
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Dohm A, Diaz R, Nanda RH. The Role of Radiation Therapy in the Older Patient. Curr Oncol Rep 2021; 23:11. [PMID: 33387104 DOI: 10.1007/s11912-020-01000-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Older patients represent a unique subgroup of the cancer patient population for which the role of radiation therapy (RT) requires special consideration. This review will discuss many of these considerations as well as various radiation treatment techniques in the context of a variety of disease sites. RECENT FINDINGS Several recent studies give insight into the management of older cancer patients considering their age, performance status, comorbid conditions, quality of life, genetics, cost, and individual goals. RT plays an evolving and pivotal role in providing optimal care for this population. Recent advances in RT technique allow for more precise treatment delivery and reduced toxicity. Studies evaluating the use of radiation therapy in breast, brain, lung, prostate, rectal, pancreatic, esophageal, and oligometastatic cancer are summarized and discussed in the context of treating the older patient population. Individual age, performance and functional status, comorbid conditions, and patients' objectives and goals should all be considered when presenting treatment options for older patients and age alone should not disqualify patients from curative intent treatments. When possible, hypofractionated courses should be utilized as outcomes are often equivalent and toxicities are reduced. In many cases, RT may be preferable to other treatment options due to decreased toxicity profile and acceptable disease control.
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Affiliation(s)
- Ammoren Dohm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Roberto Diaz
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Ronica H Nanda
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA.
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50
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Mazzarotto R, Simoni N, Guariglia S, Rossi G, Micera R, De Robertis R, Pierelli A, Zivelonghi E, Malleo G, Paiella S, Salvia R, Cavedon C, Milella M, Bassi C. Dosimetric Feasibility Study of Dose Escalated Stereotactic Body Radiation Therapy (SBRT) in Locally Advanced Pancreatic Cancer (LAPC) Patients: It Is Time to Raise the Bar. Front Oncol 2020; 10:600940. [PMID: 33392093 PMCID: PMC7773844 DOI: 10.3389/fonc.2020.600940] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
Background and Objective To assess the dosimetric feasibility of a stereotactic body radiotherapy (SBRT) dose escalated protocol, with a simultaneous integrated boost (SIB) and a simultaneous integrated protection (SIP) approach, in patients with locally advanced pancreatic cancer (LAPC). Material and Methods Twenty LAPC lesions, previously treated with SBRT at our Institution, were re-planned. The original prescribed and administered dose was 50/30/25 Gy in five fractions to PTVsib (tumor-vessel interface [TVI])/PTVt (tumor volume)/PTVsip (overlap area between PTVt and planning organs at risk volume [PRVoars]), respectively. At re-planning, the prescribed dose was escalated up to 60/40/33 Gy in five fractions to PTVsib/PTVt/PTVsip, respectively. All plans were performed using an inspiration breath hold (IBH) technique and generated with volumetric modulated arc therapy (VMAT). Well-established and accepted OAR dose constraints were used (D0.5cc < 33 Gy for luminal OARs and D0.5cc < 38 Gy for corresponding PRVoars). The primary end-point was to achieve a median dose equal to the prescription dose for the PTVsib with D98≥ 95% (95% of prescription dose is the minimum dose), and a coverage for PTVt and PTVsip of D95≥95%, with minor deviations in OAR dose constraints in < 10% of the plans. Results PTVsib median (± SD) dose/D95/conformity index (CI) were 60.54 (± 0.85) Gy/58.96 (± 0.86) Gy/0.99 (± 0.01), respectively; whilst PTVt median (± SD) dose/D95 were 44.51 (± 2.69) Gy/38.44 (± 0.82) Gy, and PTVsip median (± SD) dose/D95 were 35.18 (± 1.42) Gy/33.01 (± 0.84) Gy, respectively. With regard to OARs, median (± SD) maximum dose (D0.5cc) to duodenum/stomach/bowel was 29.31 (± 5.72) Gy/25.29 (± 6.90) Gy/27.03 (± 5.67) Gy, respectively. A minor acceptable deviation was found for a single plan (bowel and duodenum D0.5cc=34.8 Gy). V38 < 0.5 cc was achieved for all PRV luminal OARs. Conclusions In LAPC patients SBRT, with a SIB/SIP dose escalation approach up to 60/40/33 Gy in five fractions to PTVsib/PTVt/PTVsip, respectively, is dosimetrically feasible with adequate PTVs coverage and respect for OAR dose constraints.
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Affiliation(s)
- Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Renato Micera
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | | | - Alessio Pierelli
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Emanuele Zivelonghi
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Michele Milella
- Department of Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
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