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Tchelebi LT, Winter KA, Abrams RA, Safran HP, Regine WF, McNulty S, Wu A, Du KL, Seaward SA, Bian SX, Aljumaily R, Shivnani A, Knoble JL, Crocenzi TS, DiPetrillo TA, Roof KS, Crane CH, Goodman KA. Analysis of Radiation Therapy Quality Assurance in NRG Oncology RTOG 0848. Int J Radiat Oncol Biol Phys 2024; 118:107-114. [PMID: 37598723 PMCID: PMC10843017 DOI: 10.1016/j.ijrobp.2023.08.014] [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: 03/08/2023] [Revised: 07/07/2023] [Accepted: 08/07/2023] [Indexed: 08/22/2023]
Abstract
PURPOSE NRG/Radiation Therapy Oncology Group 0848 is a 2-step randomized trial to evaluate the benefit of the addition of concurrent fluoropyrimidine and radiation therapy (RT) after adjuvant chemotherapy (second step) for patients with resected pancreatic head adenocarcinoma. Real-time quality assurance (QA) was performed on each patient who underwent RT. This analysis aims to evaluate adherence to protocol-specified contouring and treatment planning and to report the types and frequencies of deviations requiring revisions. METHODS AND MATERIALS In addition to a web-based contouring atlas, the protocol outlined step-by-step instructions for generating the clinical treatment volume through the creation of specific regions of interest. The planning target volume was a uniform 0.5 cm clinical treatment volume expansion. One of 2 radiation oncology study chairs independently reviewed each plan. Plans with unacceptable deviations were returned for revision and resubmitted until approved. Treatment started after final approval of the RT plan. RESULTS From 2014 to 2018, 354 patients were enrolled in the second randomization. Of these, 160 patients received RT and were included in the QA analysis. Resubmissions were more common for patients planned with 3-dimensional conformal RT (43%) than with intensity modulated RT (31%). In total, at least 1 resubmission of the treatment plan was required for 33% of patients. Among patients requiring resubmission, most only needed 1 resubmission (87%). The most common reasons for resubmission were unacceptable deviations with respect to the preoperative gross target volume (60.7%) and the pancreaticojejunostomy (47.5%). CONCLUSION One-third of patients required resubmission to meet protocol compliance criteria, demonstrating the continued need for expending resources on real-time, pretreatment QA in trials evaluating the use of RT, particularly for pancreas cancer. Rigorous QA is critically important for clinical trials involving RT to ensure that the true effect of RT is assessed. Moreover, RT QA serves as an educational process through providing feedback from specialists to practicing radiation oncologists on best practices.
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Affiliation(s)
- Leila T Tchelebi
- Northwell, New Hyde Park, New York; Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
| | - Kathryn A Winter
- Statistics and Data Management Center, NRG Oncology, Philadelphia, Pennsylvania
| | - Ross A Abrams
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois
| | - Howard P Safran
- Department of Hematology & Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - William F Regine
- Department of Radiation Oncology, University of Maryland/Greenebaum Cancer Center, Baltimore, Maryland
| | - Susan McNulty
- Department of Clinical Research, NRG Oncology/IROC, Philadelphia, Pennsylvania
| | - Abraham Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kevin L Du
- Department of Radiation Oncology, Yale School of Medicine, Smilow Cancer Hospital, New Haven, Connecticut
| | - Samantha A Seaward
- Department of Radiation Oncology, Kaiser Permanente NCI Community Oncology Research Program, Vallejo, California
| | - Shelly X Bian
- Department of Radiation Oncology, USC / Norris Comprehensive Cancer Center, Los Angeles, California
| | - Raid Aljumaily
- Department of Hematology & Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Anand Shivnani
- Department of Radiation Oncology, The US Oncology Network, McKinney, Texas
| | - Jeanna L Knoble
- Department of Hematology & Oncology, Columbus NCI Community Oncology Research Program, Columbus, Ohio
| | - Todd S Crocenzi
- Department of Hematology & Oncology, Providence Portland Medical Center, Portland, Oregon
| | | | - Kevin S Roof
- Department of Radiation Oncology, Novant Health Presbyterian Center, Charlotte, North Carolina
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karyn A Goodman
- Department of Radiation Oncology, Mount Sinai Hospital, New York, New York.
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Gottumukkala S, Salamekh S, Sanford NN. Current State and Future Directions of Radiation Therapy for Pancreas Adenocarcinoma. Surg Oncol Clin N Am 2023; 32:399-414. [PMID: 37182984 DOI: 10.1016/j.soc.2023.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Studies suggest select patients from across the pancreatic adenocarcinoma (PDAC) disease spectrum may benefit from adding radiation therapy (RT) to multi-modality care. In resectable PDAC, there is an evolving role for neoadjuvant RT with adjuvant RT reserved for patients with increased recurrence risk. In borderline resectable PDAC, neoadjuvant chemoradiation likely improves R0 resection rates and in unresectable PDAC, definitive RT may prolong survival for some patients. Recent developments in RT delivery are promising but additional studies are needed to determine the benefit of these technologies and to optimize the role of RT in multi-modality care.
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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4
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Salamekh S, Gottumukkala S, Park C, Lin MH, Sanford NN. Radiotherapy for Pancreatic Adenocarcinoma: Recent Developments and Advances on the Horizon. Hematol Oncol Clin North Am 2022; 36:995-1009. [PMID: 36154787 DOI: 10.1016/j.hoc.2022.06.002] [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] [Indexed: 11/18/2022]
Abstract
Current indications for radiotherapy in pancreatic cancer vary by surgical resectability status of the tumor. Radiation is generally not used pre-operatively for resectable tumors, but may be given adjuvantly particularly in settings of a close or positive surgical margin. For borderline resectable tumors, pre-operative radiation has been shown to improve surgical parameters including lowering nodal positivity and positive margin rates. For locally advanced unresectable tumors, radiation can improve local control, give patients an interval off of chemotherapy and provide symptomatic relief. Multidisciplinary discussion is critical for choosing the best modality and sequencing of care for patients with pancreatic cancer. Prospective trials with appropriately chosen endpoints and meticulous radiotherapy quality assurance are needed to best define populations with pancreatic cancer most likely to benefit from radiotherapy.
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Affiliation(s)
- Samer Salamekh
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Sujana Gottumukkala
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Chunjoo Park
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Mu-Han Lin
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern, 2280 Inwood Road, Dallas, TX 75390, USA.
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5
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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6
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Hama Y, Tate E. High-dose planned adaptive intensity-modulated radiation therapy with simultaneous integrated boost for synchronous oligometastatic pancreatic cancer. Cancer Invest 2022; 40:437-441. [PMID: 35236196 DOI: 10.1080/07357907.2022.2049287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The purpose of this study was to investigate the efficacy and feasibility of high-dose (72.6 Gy) planned adaptive intensity modulated radiation therapy (IMRT) with simultaneous integrated boost (SIB) for 9 consecutive patients with synchronous oligometastatic pancreatic ductal adenocarcinoma (PDAC). The estimated 2-year overall survival rate was 66.7%, and the local progression-free survival at 2 years was 83.3%. No severe adverse events were observed. Planned adaptive dose-escalated IMRT-SIB has the potential to improve local control rate and prolong overall survival in patients with synchronous oligometastatic PDAC.
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Affiliation(s)
- Yukihiro Hama
- Department of Radiation Oncology, Tokyo-Edogawa Cancer Centre, Edogawa Hospital, Tokyo, Japan
| | - Etsuko Tate
- Department of Radiation Oncology, Tokyo-Edogawa Cancer Centre, Edogawa Hospital, Tokyo, Japan
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7
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Elective Target Coverage for Pancreatic Cancer: When Less Does Not Clearly Achieve More. Int J Radiat Oncol Biol Phys 2022; 112:143-145. [PMID: 34919872 DOI: 10.1016/j.ijrobp.2021.08.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/15/2021] [Indexed: 01/08/2023]
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8
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Valentini V, Cellini F, Riddell A, Brunner TB, Roeder F, Giuliante F, Alfieri S, Manfredi R, Ardito F, Fiorillo C, Porziella V, Morganti AG, Haustermans K, Margaritora S, De Bari B, Matzinger O, Gkika E, Belka C, Allum W, Verheij M. ESTRO ACROP guidelines for the delineation of lymph nodal areas in upper gastrointestinal malignancies. Radiother Oncol 2021; 164:92-97. [PMID: 34547352 DOI: 10.1016/j.radonc.2021.08.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
The European SocieTy for Radiation and Oncology -Advisory Committee on Radiation Oncology Practice (ESTRO-ACROP) endorsed a project to provide guidelines (GL) for the identification and delineation of clinically negative lymph-nodal stations (LNs) involved in upper gastrointestinal clinical scenarios. The presented GL is focused on preoperative (or definitive) setting. The project aim is to improve the consistency of clinical target volume (CTV) delineation by providing: a description of the anatomical boundaries of the LNs; a radiological computed tomography-based atlas depicting the LNs areas; a free, web-based, interactive example case for independent training of radiation oncologists on LNs delineation according to the presented GL, by both qualitative and quantitative analysis (through the FALCON EduCase platform). This project was carried out with the intention to facilitate and improve uniformity of future upper gastrointestinal guidelines on nodal CTV delineation. We report methodology and results from the collaboration of a working group panel selected by the ESTRO-ACROP.
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Affiliation(s)
- Vincenzo Valentini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy; Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini,. Radioterapia Oncologica ed Ematologia, Rome, Italy.
| | - Francesco Cellini
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy; Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini,. Radioterapia Oncologica ed Ematologia, Rome, Italy.
| | - Angela Riddell
- Department of Diagnostic Radiology, The Royal Marsden, London, United Kingdom.
| | - Thomas B Brunner
- Department of Radiation Oncology, University Hospital Magdeburg, Germany.
| | - Falk Roeder
- Department of Radiotherapy and Radiation Oncology, Paracelsus Medical University Salzburg, Landeskrankenhaus, Salzburg, Austria.
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico A. Gemelli - IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy.
| | - Sergio Alfieri
- Divisione di Chirurgia Digestiva, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS; Largo Agostino Gemelli, 8, 00168, Rome (Italy); CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome (Italy); Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome (Italy).
| | - Riccardo Manfredi
- Università Cattolica del Sacro Cuore, Dipartimento Universitario Diagnostica per immagini,. Radioterapia Oncologica ed Ematologia, Rome, Italy.
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico A. Gemelli - IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy.
| | - Claudio Fiorillo
- Divisione di Chirurgia Digestiva, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS; Largo Agostino Gemelli, 8, 00168, Rome (Italy); CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome (Italy); Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome (Italy).
| | - Venanzio Porziella
- Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Roma, Italy; Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna; Bologna, Italy; DIMES, Alma Mater Studiorum - Bologna University; Bologna, Italy.
| | | | - Stefano Margaritora
- Thoracic Surgery, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Roma, Italy.
| | - Berardino De Bari
- Radiation Oncology Department, Réseau hospitalier Neuchâtelois, La Chaux-de-Fonds, Switzerland.
| | - Oscar Matzinger
- Department of Radiation Oncology, Genolier Clinic, Genolier, Switzerland.
| | - Eleni Gkika
- Department of Radiation Oncology, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | - Claus Belka
- Department of Radiation Oncology, University of Munich (LMU), Munich, Germany.
| | - William Allum
- Dept of Academic Surgery Royal Marsden NHS Foundation Trust, London, United Kingdom.
| | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands; Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands.
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Basics and Frontiers on Pancreatic Cancer for Radiation Oncology: Target Delineation, SBRT, SIB technique, MRgRT, Particle Therapy, Immunotherapy and Clinical Guidelines. Cancers (Basel) 2020; 12:cancers12071729. [PMID: 32610592 PMCID: PMC7407382 DOI: 10.3390/cancers12071729] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
Pancreatic cancer represents a modern oncological urgency. Its management is aimed to both distal and local disease control. Resectability is the cornerstone of treatment aim. It influences the clinical presentation’s definitions as up-front resectable, borderline resectable and locally advanced (unresectable). The main treatment categories are neoadjuvant (preoperative), definitive and adjuvant (postoperative). This review will focus on (i) the current indications by the available national and international guidelines; (ii) the current standard indications for target volume delineation in radiotherapy (RT); (iii) the emerging modern technologies (including particle therapy and Magnetic Resonance [MR]-guided-RT); (iv) stereotactic body radiotherapy (SBRT), as the most promising technical delivery application of RT in this framework; (v) a particularly promising dose delivery technique called simultaneous integrated boost (SIB); and (vi) a multimodal integration opportunity: the combination of RT with immunotherapy.
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Umezawa R, Ito Y, Wakita A, Nakamura S, Okamoto H, Takahashi K, Inaba K, Murakami N, Igaki H, Jingu K, Itami J. How Much Was the Elective Lymph Node Region Covered in Involved-Field Radiation Therapy for Locally Advanced Pancreatic Cancer? Evaluation of Overlap Between Gross Target Volume and Celiac Artery-Superior Mesenteric Artery Lymph Node Regions. Adv Radiat Oncol 2020; 5:377-387. [PMID: 32529131 PMCID: PMC7278027 DOI: 10.1016/j.adro.2019.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose The purpose of this study was to investigate the overlaps between gross target volume (GTV) and the celiac artery (CA) and superior mesenteric artery (SMA) lymph node regions and to examine the dose incidentally irradiated to the CA and SMA lymph node regions by involved-field radiation therapy (IFRT) for locally advanced pancreatic cancer (LAPC). Methods and Materials Fifty-nine patients who had LAPC without distant metastasis were included. They received IFRT at 50.4 Gy in 28 fractions with 3-dimensional conformal radiation therapy. We calculated the percentages of overlap of GTV in the CA and SMA lymph node regions and examined what cases tend to have an overlap. We also investigated the dose metrics of CA and SMA lymph node regions by IFRT and the frequency of CA or SMA lymph node metastasis after IFRT. Results The median GTV volume was 52.2 mL. Median overlap percentages in the CA and SMA lymph node regions were 39.2% and 28.6%, respectively. There was a significant correlation between GTV volume and SMA overlap percentage (P < .001). Although the SMA overlap percentage was higher in the pancreas head (P = .028), the CA overlap percentage was higher in the pancreas body or tail (P = .002). Median mean dose, D95, and minimum dose in the CA lymph node region were 50.1 Gy, 48.7 Gy, and 45.9 Gy, respectively, and those in the SMA lymph node region 49.9 Gy, 47.3 Gy, and 39.2 Gy, respectively. CA lymph node metastases after IFRT were detected in 4 patients (6.8%). Conclusions An overlap between GTV and CA-SMA lymph node regions was detected in many patients, and the CA and SMA lymph node regions were irradiated incidentally even by IFRT. Prophylactic lymph node regions might not be necessary in radiation therapy planning of LAPC.
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Affiliation(s)
- Rei Umezawa
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Radiation Oncology, Showa University School of Medicine, Tokyo, Japan
| | - Akihisa Wakita
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Okamoto
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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11
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Abstract
BACKGROUND The clinical target volume (CTV) is regarded fundamental for radiotherapy planning by the International Commission on Radiation Units and Measurements (ICRU). OBJECTIVES The aim of this article is to give an overview on the basics and problems of defining the CTV for radiotherapy planning. MATERIALS AND METHODS After briefly defining CTV, a short description of the process to homogenize CTV in intraindividual comparisons is given, where special attention is paid to radiological requirements. This information is summarized in a number of tables. RESULTS CTV is the most complex volume among the target volumes that have been defined by the ICRU. A survey of the determinants of the definition of CTV is given. CONCLUSIONS This overview on the basic rules of how to define CTVs can help to increase the understanding of the radiological requirements for optimum imaging to support radiotherapy planning regardless of the specialty of the physician.
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Affiliation(s)
- T B Brunner
- Universitätsklinik für Strahlentherapie, Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland.
| | - M Walke
- Universitätsklinik für Strahlentherapie, Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland
| | - P Hass
- Universitätsklinik für Strahlentherapie, Medizinische Fakultät, Otto-von-Guericke-Universität Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Deutschland
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12
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Caravatta L, Cellini F, Simoni N, Rosa C, Niespolo RM, Lupattelli M, Picardi V, Macchia G, Sainato A, Mantello G, Dionisi F, Rosetto ME, Fusco V, Navarria F, De Paoli A, Guido A, Vecchi C, Basilico R, Cianci R, Delli Pizzi A, Di Nicola M, Mattiucci GC, Valentini V, Morganti AG, Genovesi D. Magnetic resonance imaging (MRI) compared with computed tomography (CT) for interobserver agreement of gross tumor volume delineation in pancreatic cancer: a multi-institutional contouring study on behalf of the AIRO group for gastrointestinal cancers. Acta Oncol 2019; 58:439-447. [PMID: 30632876 DOI: 10.1080/0284186x.2018.1546899] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Due to the high soft tissue resolution, magnetic resonance imaging (MRI) could improve the accuracy of pancreatic tumor delineation in radiation treatment planning. A multi-institutional study was proposed to evaluate the impact of MRI on inter-observer agreement in gross tumor volume (GTV) and duodenum delineation for pancreatic cancer compared with computer tomography (CT). MATERIAL AND METHODS Two clinical cases of borderline resectable (Case 1) and unresectable (Case 2) pancreatic cancer were selected. In two sequential steps, diagnostic contrast-enhanced CT scan and MRI sequences were sent to the participating centers. CT-GTVs were contoured while blinded to MRI data sets. DICE index was used to evaluate the spatial overlap accuracy. RESULTS Thirty-one radiation oncologists from different Institutions submitted the delineated volumes. CT- and MRI-GTV mean volumes were 21.6 ± 9.0 cm3 and 17.2 ± 6.0 cm3, respectively for Case 1, and 31.3 ± 15.6 cm3 and 33.2 ± 20.2 cm3, respectively for Case 2. Resulting MRI-GTV mean volume was significantly smaller than CT-GTV in the borderline resectable case (p < .05). A substantial agreement was shown by the median DICE index for CT- and MRI-GTV resulting as 0.74 (IQR: 0.67-0.75) and 0.61 (IQR: 0.57-0.67) for Case 1; a moderate agreement was instead reported for Case 2: 0.59 (IQR:0.52-0.66) and 0.53 (IQR:0.42-0.62) for CT- and MRI-GTV, respectively. CONCLUSION Diagnostic MRI resulted in smaller GTV in borderline resectable case with a substantial agreement between observers, and was comparable to CT scan in interobserver variability, in both cases. The greater variability in the unresectable case underlines the critical issues related to the outlining when vascular structures are more involved. The integration of MRI with contrast-enhancement CT, thanks to its high definition of tumor relationship with neighboring vessels, could offer a greater accuracy of target delineation.
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Affiliation(s)
- Luciana Caravatta
- Department of Radiotherapy, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Francesco Cellini
- Gemelli Advanced Radiation Therapy Center Fondazione Policlinico Universitario ‘A. Gemelli’ Catholic University of Sacred Heart, Rome, Italy
| | - Nicola Simoni
- Radiotherapy Unit Azienda Ospedaliera Universitaria, Verona, Italy
| | - Consuelo Rosa
- Department of Radiotherapy, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | | | - Marco Lupattelli
- Radiation Oncology Section University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Vincenzo Picardi
- Radiotherapy Unit Department of Oncology, ‘Giovanni Paolo II’ Foundation Catholic University of Sacred Heart, Campobasso, Italy
| | - Gabriella Macchia
- Radiotherapy Unit Department of Oncology, ‘Giovanni Paolo II’ Foundation Catholic University of Sacred Heart, Campobasso, Italy
| | - Aldo Sainato
- Radiotherapy Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | | | - Francesco Dionisi
- Proton Therapy Unit, Department of Oncology, Azienda Provinciale per i Servizi Sanitari, APSS, Trento, Italy
| | | | - Vincenzo Fusco
- Department of Radiation Oncology, Centro di Riferimento Oncologico Regionale, Rionero in Vulture, Potenza, Italy
| | - Federico Navarria
- Department of Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Antonino De Paoli
- Department of Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Alessandra Guido
- Radiation Oncology Center, Department of Experimental Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Raffaella Basilico
- Department of Radiology, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Roberta Cianci
- Department of Radiology, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Andrea Delli Pizzi
- Department of Radiology, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics Department of Medical, Oral and Biotechnological Sciences ‘G. D'Annunzio’ University, Chieti, Italy
| | - Gian Carlo Mattiucci
- Gemelli Advanced Radiation Therapy Center Fondazione Policlinico Universitario ‘A. Gemelli’ Catholic University of Sacred Heart, Rome, Italy
| | - Vincenzo Valentini
- Gemelli Advanced Radiation Therapy Center Fondazione Policlinico Universitario ‘A. Gemelli’ Catholic University of Sacred Heart, Rome, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology Center, Department of Experimental Diagnostic and Specialty Medicine - DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Domenico Genovesi
- Department of Radiotherapy, ‘SS Annunziata’ Hospital ‘G. D’Annunzio’ University, Chieti, Italy
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13
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Yegya-Raman N, Shah MM, Grandhi MS, Poplin E, August DA, Kennedy TJ, Malhotra U, Spencer KR, Carpizo DR, Jabbour SK. Adjuvant therapeutic strategies for resectable pancreatic adenocarcinoma. ACTA ACUST UNITED AC 2018; 1. [PMID: 30687847 DOI: 10.21037/apc.2018.07.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Of all patients diagnosed with pancreatic adenocarcinoma, only 15-20% present with resectable disease. Despite curative-intent resection, the prognosis remains poor with the majority of patients recurring, prompting the need for adjuvant therapy. Historical data support the use of adjuvant 5-fluorouracil (5-FU) or gemcitabine, but recent data suggest either gemcitabine plus capecitabine or modified FOLFIRINOX can improve overall survival when compared to gemcitabine alone. The use of adjuvant chemoradiation therapy remains controversial, primarily due to limitations in study design and mixed results of historical trials. The ongoing Radiation Therapy Oncology Group (RTOG)-0848 trial hopes to further define the role of adjuvant chemoradiation therapy. Intraoperative radiation therapy (IORT) and adjuvant immunotherapy represent additional possibilities to improve outcomes, but evidence supporting their use is limited. This article reviews adjuvant therapeutic strategies for resectable pancreatic adenocarcinoma, including chemotherapy, chemoradiation therapy, IORT and immunotherapy.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Miral S Grandhi
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Elizabeth Poplin
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - David A August
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Timothy J Kennedy
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Usha Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Kristen R Spencer
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Darren R Carpizo
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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14
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Cheng Q, Han LH, Zhao HJ, Li H, Li JB. Abnormal alterations of miR-1 and miR-214 are associated with clinicopathological features and prognosis of patients with PDAC. Oncol Lett 2017; 14:4605-4612. [PMID: 29085459 PMCID: PMC5649611 DOI: 10.3892/ol.2017.6819] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 07/27/2017] [Indexed: 12/20/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a devastating malignant disease with a poor prognosis. PDAC is known to be difficult to diagnose at an early stage and to exhibit poor recurrence-free prognosis, but there is also a lack of effective treatment and limited knowledge of its biological characteristics. Therefore, there is an urgent requirement for an improved understanding of the cellular or molecular properties associated with PDAC, and to explore novel avenues for the diagnosis and treatment of this disease. In the present study, the microRNA (miRNA/miR) profiles of sera and tumor samples from patients with PDAC and healthy controls were investigated by miRNA microarray, and the potential role of miR-1 expression in PDAC was determined. A total of 43 patients attending the clinic diagnosed with PDAC at Changzhi City People's Hospital were invited to participate. Blood and surgical tumor samples were obtained for analysis by miRNA microarray and the reverse transcription-quantitative polymerase chain reaction (RT-qPCR). The surgical tumor tissue was additionally used to determine miRNAs status by in situ hybridization (ISH). The results of microarray revealed that: i) 27 miRNAs in the sera and 23 miRNAs in the tumor tissues obtained from patients with PDAC were different compared with their matched controls; ii) miR-1, miR-10b and miR-214 were significantly altered in the PDAC group, either in the sera or tumor tissue samples. Results from the RT-qPCR, which detected the levels of miRNAs in patients with PDAC, confirmed those obtained from the miRNA microarray. In particular, the results of the present study revealed that decreased miR-1 and increased miR-214 in the PDAC tissues were associated with the clinicopathological features and survival rates of patients with PDAC. The results of the present study indicated that miRNAs serve an important role in PDAC carcinogenic progression and supplied useful markers, including miR-1, miR-214 and miR-10b, for determining PDAC prognosis using noninvasive methods.
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Affiliation(s)
- Qing Cheng
- Gerontology Department, Changzhi City People's Hospital, Changzhi, Shanxi 046000, P.R. China
| | - Li-Hua Han
- Gerontology Department, Changzhi City People's Hospital, Changzhi, Shanxi 046000, P.R. China
| | - Hai-Juan Zhao
- Gerontology Department, Changzhi City People's Hospital, Changzhi, Shanxi 046000, P.R. China
| | - Hui Li
- Gerontology Department, Changzhi City People's Hospital, Changzhi, Shanxi 046000, P.R. China
| | - Jian-Bing Li
- Gerontology Department, Changzhi City People's Hospital, Changzhi, Shanxi 046000, P.R. China
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Abstract
Pancreatic cancer is the most lethal gastrointestinal tumour. Chemotherapy is the mainstay of therapy in the majority of the patients whereas resection is the only chance of cure but only possible in 15-20% of all patients. The integration of radiotherapy into multimodal treatment concepts is heavily investigated. It is now commonly accepted that induction chemotherapy should precede radiotherapy. When fractionated conventionally it should be given as chemoradiotherapy. Recently, stereotactic body radiotherapy emerged as an alternative, but will have to be carefully investigated in clinical trials. This review aims to give an overview of radiotherapeutic strategies with a focus on the latest developments in the field in the context of chemotherapy and surgery.
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16
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Macchia G, Sainato A, Talamini R, Boz G, Bacigalupo A, Caravatta L, Fiore M, Friso ML, Fusco V, Lupattelli M, Mantello G, Mattiucci GC, Slim N, Sciacero P, Turri L, Valentini V, Morganti AG, Genovesi D. Patterns of radiotherapy practice for pancreatic cancer: Results of the Gastrointestinal Radiation Oncology Study Group multi-institutional survey. Oncol Rep 2015; 34:382-90. [PMID: 25955190 DOI: 10.3892/or.2015.3955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 01/05/2015] [Indexed: 11/06/2022] Open
Abstract
No information is currently available regarding pancreatic cancer (PC) pattern of care in Italy. In the present study, a nationwide survey using a questionnaire was performed to enquire the local standards for PC diagnosis and radiotherapy treatment. Fifty-seven percent of 140 Italian centres completed questionnaire. The main causes of no radiotherapy indication were poor general condition (45%) and lack of guidelines (25%). Physicians (38%) employed neoadjuvant therapy in locally advanced PC patients, while in other centres (62%) adjuvant chemoradiation was administered. Adjuvant gemcitabine-based chemotherapy was selected as the treatment of choice by 59% of centres. Patients were treated mostly with doses of 50-54.9 Gy on the tumour (or bed) plus lymph nodes. A 3D-CRT technique was used in 81.2% of centres, while IMRT and IGRT were available in 61.2 and 48.7% of cases, respectively. Extensive variation exists with regard to patterns of care for PC in Italy. Nevertheless, cooperative studies emerging from this survey appeared beneficial.
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Affiliation(s)
- Gabriella Macchia
- Radiation Oncology Unit, Research and Care Foundation 'Giovanni Paolo II', Catholic University of Sacred Heart, Campobasso, Italy
| | - Aldo Sainato
- Radiation Oncology Unit, University Hospital, Pisa, Italy
| | - Renato Talamini
- Epidemiology and Biostatistics Unit, Oncological Referral Center, Aviano, Italy
| | - Giovanni Boz
- Radiation Oncology Department, Oncological Referral Center, Aviano, Italy
| | - Almalina Bacigalupo
- Radiation Oncology Unit, AOU IRCCS San Martino, IST National Cancer Research Institute, Genoa, Italy
| | - Luciana Caravatta
- Radiation Oncology Department, 'A. Businco' Regional Oncological Hospital, Cagliari, Italy
| | - Michele Fiore
- Radiation Oncology Unit, Campus Bio-Medico University Hospital, Rome, Italy
| | - Maria Luisa Friso
- Radiotherapy and Nuclear Medicine Unit, Veneto Institute of Oncology-IRCCS, Padua, Italy
| | - Vincenzo Fusco
- Radiation Oncology Unit, IRCCS CROB, Rionero in Vulture, Potenza, Italy
| | - Marco Lupattelli
- Radiation Oncology Unit, 'S. Maria della Misericordia' Hospital, Perugia, Italy
| | | | - Gian Carlo Mattiucci
- Radiation Oncology Department, 'A. Gemelli' Hospital, Catholic University of Sacred Heart, Rome, Italy
| | - Najla Slim
- Radiation Oncology Unit, 'San Raffaele' Hospital, Milan, Italy
| | - Piera Sciacero
- Radiation Oncology Unit, ASL TO4, General Hospital, Ivrea, Italy
| | - Lucia Turri
- Radiation Oncology Unit, 'Maggiore della Carità' Hospital, Novara, Italy
| | - Vincenzo Valentini
- Radiation Oncology Department, 'A. Gemelli' Hospital, Catholic University of Sacred Heart, Rome, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology Unit, Research and Care Foundation 'Giovanni Paolo II', Catholic University of Sacred Heart, Campobasso, Italy
| | - Domenico Genovesi
- Radiation Oncology Unit, 'SS Annunziata' Hospital, 'G. D'Annunzio' University, Chieti, Italy
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17
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Golcher H, Brunner TB, Witzigmann H, Marti L, Bechstein WO, Bruns C, Jungnickel H, Schreiber S, Grabenbauer GG, Meyer T, Merkel S, Fietkau R, Hohenberger W. Neoadjuvant chemoradiation therapy with gemcitabine/cisplatin and surgery versus immediate surgery in resectable pancreatic cancer: results of the first prospective randomized phase II trial. Strahlenther Onkol 2014; 191:7-16. [PMID: 25252602 PMCID: PMC4289008 DOI: 10.1007/s00066-014-0737-7] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 07/23/2014] [Indexed: 12/15/2022]
Abstract
Background In nonrandomized trials, neoadjuvant treatment was reported to prolong survival in patients with pancreatic cancer. As neoadjuvant chemoradiation is established for the treatment of rectal cancer we examined the value of neoadjuvant chemoradiotherapy in pancreatic cancer in a randomized phase II trial. Radiological staging defining resectability was basic information prior to randomization in contrast to adjuvant therapy trials resting on pathological staging. Patients and methods Patients with resectable adenocarcinoma of the pancreatic head were randomized to primary surgery (Arm A) or neoadjuvant chemoradiotherapy followed by surgery (Arm B), which was followed by adjuvant chemotherapy in both arms. A total of 254 patients were required to detect a 4.33-month improvement in median overall survival (mOS). Results The trial was stopped after 73 patients; 66 patients were eligible for analysis. Twenty nine of 33 allocated patients received chemoradiotherapy. Radiotherapy was completed in all patients. Chemotherapy was changed in 3 patients due to toxicity. Tumor resection was performed in 23 vs. 19 patients (A vs. B). The R0 resection rate was 48 % (A) and 52 % (B, P = 0.81) and (y)pN0 was 30 % (A) vs. 39 % (B, P = 0.44), respectively. Postoperative complications were comparable in both groups. mOS was 14.4 vs. 17.4 months (A vs. B; intention-to-treat analysis; P = 0.96). After tumor resection, mOS was 18.9 vs. 25.0 months (A vs. B; P = 0.79). Conclusion This worldwide first randomized trial for neoadjuvant chemoradiotherapy in pancreatic cancer showed that neoadjuvant chemoradiation is safe with respect to toxicity, perioperative morbidity, and mortality. Nevertheless, the trial was terminated early due to slow recruiting and the results were not significant. ISRCTN78805636; NCT00335543. Electronic supplementary material The online version of this article (doi: 10.1007/s00066-014-0737-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henriette Golcher
- Department of Surgery, University Hospital Erlangen, Krankenhausstr. 12, 91054, Erlangen, Germany,
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18
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Caravatta L, Macchia G, Mattiucci GC, Sainato A, Cernusco NLV, Mantello G, Di Tommaso M, Trignani M, De Paoli A, Boz G, Friso ML, Fusco V, Di Nicola M, Morganti AG, Genovesi D. Inter-observer variability of clinical target volume delineation in radiotherapy treatment of pancreatic cancer: a multi-institutional contouring experience. Radiat Oncol 2014; 9:198. [PMID: 25199768 PMCID: PMC4261525 DOI: 10.1186/1748-717x-9-198] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 08/31/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND An observational multi-institutional study has been conducted aimed to evaluate the inter-observer variability in clinical target volume (CTV) delineation among different radiation oncologists in radiotherapy treatment of pancreatic cancer. METHODS A multi-institutional contouring dummy-run of two different cases of pancreatic cancer treated by postoperative and preoperative radiotherapy (RT) was performed. Clinical history, diagnostics, and planning CT imaging were available on AIRO website (http://www.radioterapiaitalia.it). Participants were requested to delineate CTVs according to their skills and knowledge. Aiming to quantify interobserver variability of CTVs delineations, the total volume, craniocaudal, laterolateral, and anteroposterior diameters were calculated. Descriptive statistic was calculated. The 95% Confidence Interval (95% CI) for coefficient of variation (CV) was estimated. The Dice Similarity Index (DSI) was used to evaluate the spatial overlap accuracy of the different CTVs compared with the CTVs of a national reference Centre considered as a benchmark. The mean DSI (mDSI) was calculated and reported. RESULTS A total of 18 radiation oncologists from different Institutes submitted the targets. Less variability was observed for the Elective CTV rather than the Boost CTV, in both cases. The estimated CV were 28.8% (95% CI: 21.2-45.0%) and 20.0% (95% CI: 14.9-30.6%) for the Elective CTV, in adjuvant (Case 1) and neoadjuvant (Case 2) case, respectively. The mDSI value was 0.68 for the Elective CTVs in both cases (range 0.19-0.79 in postoperative vs range 0.35-0.79 in preoperative case). The mDSI was increased to 0.71 (Case 1) and 0.72 (Case 2) if the observers with a worse agreement have been excluded. On the other hand, a CV of 42.4% (95% CI: 30.1-72.4%) and 63.8% (95% CI: 43.9-119.2%) with a mDSI value of 0.44 and 0.52, were calculated for the Boost CTV in Case 1 and Case 2, respectively. CONCLUSIONS The CV and mDSI obtained values for Elective CTVs showed an acceptable agreement among participants either in postoperative as well in preoperative setting. Additional strategies to reduce the variability in Boost CTV delineation need to be found and promoted.
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Affiliation(s)
- Luciana Caravatta
- />Radiation Oncology Department, “San Francesco” Hospital, Via Mannironi, 1, 08110 Nuoro, Italy
| | - Gabriella Macchia
- />Radiation Oncology Department, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Campobasso, Italy
| | | | - Aldo Sainato
- />Radiotherapy Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - Nunzia LV Cernusco
- />Radiotherapy Unit, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | | | - Monica Di Tommaso
- />Department of Radiotherapy, “SS Annunziata” Hospital, “G. D’Annunzio” University, Chieti, Italy
| | - Marianna Trignani
- />Department of Radiotherapy, “SS Annunziata” Hospital, “G. D’Annunzio” University, Chieti, Italy
| | - Antonino De Paoli
- />Department of Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Gianni Boz
- />Department of Radiation Oncology Centro di Riferimento Oncologico, National Cancer Institute, Aviano, Italy
| | - Maria L Friso
- />Radiotherapy and Nuclear Medicine Unit, Istituto Oncologico Veneto, IRCCS, Padova, Italy
| | - Vincenzo Fusco
- />Department of Radiation Oncology, IRCCS CROB, Rionero in Vulture, Potenza, Italy
| | - Marta Di Nicola
- />Department of Experimental and Clinical Sciences, Laboratory of Biostatistics, “G. D’Annunzio” University, Chieti, Italy
| | - Alessio G Morganti
- />Radiation Oncology Department, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Campobasso, Italy
- />Radiotherapy Department, Università Cattolica del S. Cuore, Roma, Italy
| | - Domenico Genovesi
- />Department of Radiotherapy, “SS Annunziata” Hospital, “G. D’Annunzio” University, Chieti, Italy
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19
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Chuong MD, Boggs DH, Patel KN, Regine WF. Adjuvant chemoradiation for pancreatic cancer: what does the evidence tell us? J Gastrointest Oncol 2014; 5:166-77. [PMID: 24982765 DOI: 10.3978/j.issn.2078-6891.2014.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/08/2014] [Indexed: 12/12/2022] Open
Abstract
The role of adjuvant chemoradiation (CRT) for pancreas cancer remains unclear. A handful of randomized trials conducted decades of ago ignited a debate that continues today about whether CRT improves survival after surgery. The many flaws in these trials are well described in the literature, which include the use of antiquated radiation delivery techniques and suboptimal doses. Recent prospective randomized data is lacking, and we eagerly await the results the ongoing Radiation Therapy Oncology Group (RTOG) 0848 trial that is evaluating the utility of high quality adjuvant CRT in resected pancreas cancer patients. Until the results of RTOG 0848 are available we should look to other studies from the modern era to guide adjuvant treatment recommendations. Here we review the current state of the art for adjuvant pancreas CRT with respect to patient selection, radiation techniques, radiation dose, and integration with novel systemic agents.
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Affiliation(s)
- Michael D Chuong
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Drexell H Boggs
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - Kruti N Patel
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
| | - William F Regine
- Department of Radiation Oncology, University of Maryland Medical Systems, Baltimore, MD 21201, USA
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20
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Neoadjuvant therapy for potentially resectable pancreatic cancer: an emerging paradigm? Curr Oncol Rep 2013; 15:162-9. [PMID: 23325567 DOI: 10.1007/s11912-012-0291-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Although neoadjuvant chemoradiotherapy has been tested for more than two decades and can be safely delivered to patients with non-metastatic pancreatic cancer, no randomised trials have been reported until now. Here we provide an overview of the first randomised trial in patients with potentially resectable cancer and of the latest developments in neoadjuvant therapy for this group of patients. It is necessary to continue to perform clinical trials in this field to accurately identify the effect on survival and quality of life in patients with potentially resectable, borderline resectable and unresectable pancreatic cancer. Aspects of imaging for restaging and clinical prognostic factors are also discussed given they will be useful instruments for future trials.
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21
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A treatment planning comparison of four target volume contouring guidelines for locally advanced pancreatic cancer radiotherapy. Radiother Oncol 2013; 107:200-6. [DOI: 10.1016/j.radonc.2013.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 03/28/2013] [Accepted: 04/05/2013] [Indexed: 02/08/2023]
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22
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Fokas E, Eccles C, Patel N, Chu KY, Warren S, Gillies McKenna W, Brunner TB. Comparison of four target volume definitions for pancreatic cancer. Guidelines for treatment of the lymphatics and the primary tumor. Strahlenther Onkol 2013; 189:407-16. [PMID: 23553047 DOI: 10.1007/s00066-013-0332-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/13/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE Target volume definitions for radiotherapy in pancreatic ductal adenocarcinoma (PDAC) vary substantially. Some groups aim to treat the primary tumor only, whereas others include elective lymph nodes (eLNs). eLNs close to the primary tumor are often included unintentionally within the treatment volume, depending on the respective treatment philosophies. We aimed to measure the percentages of anatomical coverage of eLNs by comparing four different contouring guidelines. PATIENTS AND METHODS Planning target volumes (PTVs) were contoured using planning computed tomography (CT) scans of 11 patients with PDAC based on the Oxford, RTOG (Radiation Therapy Oncology Group), Michigan, and SCALOP (Selective Chemoradiation in Advanced Localised Pancreatic Cancer trial) guidelines. Clinical target volumes (CTVs) included the peripancreatic, para-aortic, paracaval, celiac trunk, superior mesenteric, and portal vein lymph node areas. Volumetric comparisons of the coverage of all eLN regions were conducted to illustrate the differences between the four contouring strategies. RESULTS The PTV sizes of the RTOG and Oxford guidelines were comparable. The SCALOP and Michigan PTV sizes were similar to each other and significantly smaller than the RTOG and Oxford PTVs. A large variability of eLN coverage was found for the various subregions according to the respective contouring strategies. CONCLUSION This is the first study to directly compare the percentage of anatomical coverage of eLNs according to four PTVs in the same patient cohort. Potential practical consequences are discussed in detail.
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Affiliation(s)
- E Fokas
- Gray Institute for Radiation Oncology and Biology, Department of Oncology, Oxford Cancer Centre, University of Oxford
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23
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Caravatta L, Sallustio G, Pacelli F, Padula GDA, Deodato F, Macchia G, Massaccesi M, Picardi V, Cilla S, Marinelli A, Cellini N, Valentini V, Morganti AG. Clinical target volume delineation including elective nodal irradiation in preoperative and definitive radiotherapy of pancreatic cancer. Radiat Oncol 2012; 7:86. [PMID: 22691275 PMCID: PMC3494529 DOI: 10.1186/1748-717x-7-86] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 06/05/2012] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Radiotherapy (RT) is widely used in the treatment of pancreatic cancer. Currently, recommendation has been given for the delineation of the clinical target volume (CTV) in adjuvant RT. Based on recently reviewed pathologic data, the aim of this study is to propose criteria for the CTV definition and delineation including elective nodal irradiation (ENI) in the preoperative and definitive treatment of pancreatic cancer. METHODS The anatomical structures of interest, as well as the abdominal vasculature were identified on intravenous contrast-enhanced CT scans of two different patients with pancreatic cancer of the head and the body. To delineate the lymph node area, a margin of 10 mm was added to the arteries. RESULTS We proposed a set of guidelines for elective treatment of high-risk nodal areas and CTV delineation. Reference CT images were provided. CONCLUSIONS The proposed guidelines could be used for preoperative or definitive RT for carcinoma of the head and body of the pancreas. Further clinical investigations are needed to validate the defined CTVs.
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Affiliation(s)
- Luciana Caravatta
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Giuseppina Sallustio
- Radiology Unit, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Fabio Pacelli
- Surgery Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Gilbert DA Padula
- Radiation Oncology Department, The Lacks Cancer Center Saint Mary’s Health Care, Grand Rapids, MI, USA
| | - Francesco Deodato
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Mariangela Massaccesi
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Vincenzo Picardi
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Savino Cilla
- Physics Unit, Fondazione di Ricerca e Cura Giovanni Paolo II, Università Cattolica del S. Cuore, Campobasso, Italy
| | - Alfonso Marinelli
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
| | - Numa Cellini
- Radiotherapy Department, Università Cattolica del S. Cuore, Rome, Italy
| | | | - Alessio G Morganti
- Radiotherapy Unit, Department of Oncology, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Università Cattolica del S. Cuore, Largo A. Gemelli 1, 86100, Campobasso, Italy
- Radiotherapy Department, Università Cattolica del S. Cuore, Rome, Italy
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Goodman KA, Regine WF, Dawson LA, Ben-Josef E, Haustermans K, Bosch WR, Turian J, Abrams RA. Radiation Therapy Oncology Group consensus panel guidelines for the delineation of the clinical target volume in the postoperative treatment of pancreatic head cancer. Int J Radiat Oncol Biol Phys 2012; 83:901-8. [PMID: 22483737 DOI: 10.1016/j.ijrobp.2012.01.022] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 01/04/2012] [Accepted: 01/05/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To develop contouring guidelines to be used in the Radiation Therapy Oncology Group protocol 0848, a Phase III randomized trial evaluating the benefit of adjuvant chemoradiation in patients with resected head of pancreas cancer. METHODS AND MATERIALS A consensus committee of six radiation oncologists with expertise in gastrointestinal radiotherapy developed stepwise contouring guidelines and an atlas for the delineation of the clinical target volume (CTV) in the postoperative treatment of pancreas cancer, based on identifiable regions of interest and margin expansions. Areas at risk for subclinical disease to be included in the CTV were defined, including nodal regions, anastomoses, and the preoperative primary tumor location. Regions of interest that could be reproducibly contoured on postoperative imaging after a pancreaticoduodenectomy were identified. Standardized expansion margins to encompass areas at risk were developed after multiple iterations to determine the optimal margin expansions. RESULTS New contouring recommendations based on CT anatomy were established. Written guidelines for the delineation of the postoperative CTV and normal tissues, as well as a Web-based atlas, were developed. CONCLUSIONS The postoperative abdomen has been a difficult area for effective radiotherapy. These new guidelines will help physicians create fields that better encompass areas at risk and minimize dose to normal tissues.
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Affiliation(s)
- Karyn A Goodman
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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25
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Brunner TB, Sauer R, Fietkau R. Gemcitabine/cisplatin versus 5-fluorouracil/mitomycin C chemoradiotherapy in locally advanced pancreatic cancer: a retrospective analysis of 93 patients. Radiat Oncol 2011; 6:88. [PMID: 21794119 PMCID: PMC3161863 DOI: 10.1186/1748-717x-6-88] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 07/27/2011] [Indexed: 12/27/2022] Open
Abstract
Background Despite of a growing number of gemcitabine based chemoradiotherapy studies in locally advanced pancreatic cancer (LAPC), 5-fluorouracil based regimens are still regarded to be standard and the debate of superiority between the two drugs is going on. The aim of this retrospective analysis was to evaluate the effect of two concurrent chemoradiotherapy regimens using 5-fluorouracil or gemcitabine to compare their effect and tolerance. Methods We have performed a single centre retrospective analysis of 93 patients treated with conventionally fractionated radiotherapy of 55.8 Gray using either concurrent 5-fluorouracil, 1 g/m² on days 1-5 and 29-33 of radiotherapy and 10 mg/m² of mitomycin C on day 1, 29 of radiotherapy (FM group, 35 patients) versus gemcitabine (300 mg/m²) and cisplatin, (30 mg/m²) on days 1, 8, 22, and 29 (GC group, 58 patients). Primary endpoint was the median overall survival (OS) rate. Results The median OS rate was 12.7 months in the GC group and 9.7 months in the FM group. The 1-year OS rate was 53% versus 40%, respectively (p = 0.009). GC led to more grade 3 leukocytopenia and thrombocytopenia than FM, but not to more grade 4 myelosuppression. Thrombocytopenia was the most frequently observed grade 4 toxicity in both groups (11% after FM versus 12% after GC). No grade 3/4 febrile neutropenia was observed. Grade 3 nausea was more common in the FM group (20% versus 9%) and grade 4 nausea was observed in one patient per group only. Conclusions GC was superior to FM for overall survival and both regimens were similar in terms of tolerance. We conclude that GC leads to encouraging results and that the use of FM for chemoradiotherapy in LAPC cannot be recommended without concerns.
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Affiliation(s)
- Thomas B Brunner
- Radiation Oncology of the Friedrich-Alexander University of Erlangen-Nuremberg, Universitätsstraße 22, 91054 Erlangen, Germany.
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Brunner TB, Scott-Brown M. The role of radiotherapy in multimodal treatment of pancreatic carcinoma. Radiat Oncol 2010; 5:64. [PMID: 20615227 PMCID: PMC2911464 DOI: 10.1186/1748-717x-5-64] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 07/08/2010] [Indexed: 01/04/2023] Open
Abstract
Pancreatic ductal carcinoma is one of the most lethal malignancies, but in recent years a number of positive developments have occurred in the management of pancreatic carcinoma. This article aims to give an overview of the current knowledge regarding the role of radiotherapy in the treatment of pancreatic ductal adenocarcinoma (PDAC). The results of meta-analyses, phase III-studies, and phase II-studies using chemoradiotherapy and chemotherapy for resectable and non-resectable PDAC were reviewed. The use of radiotherapy is discussed in the neoadjuvant and adjuvant settings as well as in the locally advanced situation. Whenever possible, radiotherapy should be performed as simultaneous chemoradiotherapy. Patients with PDAC should be offered entry into clinical trials to identify optimal treatment results.
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Affiliation(s)
- Thomas B Brunner
- Gray Institute for Radiation Oncology & Biology, University of Oxford, Oxford, UK
| | - Martin Scott-Brown
- Gray Institute for Radiation Oncology & Biology, University of Oxford, Oxford, UK
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Volumetric Modulated Arc Therapy for Advanced Pancreatic Cancer. Strahlenther Onkol 2010; 186:382-7. [DOI: 10.1007/s00066-010-2094-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 02/24/2010] [Indexed: 11/26/2022]
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Sun W, Leong CN, Zhang Z, Lu JJ. Proposing the lymphatic target volume for elective radiation therapy for pancreatic cancer: a pooled analysis of clinical evidence. Radiat Oncol 2010; 5:28. [PMID: 20398316 PMCID: PMC2859771 DOI: 10.1186/1748-717x-5-28] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 04/15/2010] [Indexed: 02/08/2023] Open
Abstract
Background Radiation therapy is an important cancer treatment modality in both adjuvant and definitive setting, however, the use of radiation therapy for elective treatment of regional lymph nodes is controversial for pancreatic cancer. No consensus on proper selection and delineation of subclinical lymph nodal areas in adjuvant or definitive radiation therapy has been suggested either conclusively or proposed for further investigation. This analysis aims to study the pattern of lymph node metastasis through a pooled analysis of published results after radical tumor and lymph nodal resection with histological study in pancreatic cancer. Methods Literature search using electronic databases including MEDLINE, EMBASE, and CANCERLIT from January 1970 to June 2009 was performed, supplemented by review of references. Eighteen original researches and a total of 5954 pancreatic cancer patients underwent radical surgical resection were included in this analysis. The probability of metastasis in regional lymph nodal stations (using Japan Pancreas Society [JPS] Classification) was calculated and analyzed based on the location and other characteristics of the primary disease. Results Commonly involved nodal regions in patients with pancreatic head tumor include lymph nodes around the common hepatic artery (Group 8, 9.79%), posterior pancreaticoduodenal lymph nodes (Group 13, 32.31%), lymph nodes around the superior mesenteric artery (Group 14, 15.85%), paraaortic lymph nodes (Group 16, 10.92%), and anterior pancreaticoduodenal lymph nodes (Group 17, 19.78%); The probability of metastasis in other lymph nodal regions were <9%. Commonly involved nodal regions in patients with pancreatic body/tail tumor include lymph nodes around the common hepatic artery (Group 8, 15.07%), lymph nodes around the celiac trunk (Group 9, 9.59%), lymph nodes along the splenic artery (Group 11, 35.62%), lymph nodes around the superior mesenteric artery (Group 14, 9.59%), paraaortic lymph nodes (Group 16, 16.44%), and inferior body lymph nodes (Group 18, 24.66%). The probability of metastasis in other lymph nodal regions were <9%. Conclusions Pancreatic cancer has a high propensity of regional lymphatic metastases; however, clear patterns including the site and probability of metastasis can be identified and used as a guide of treatment in patients with resectable pancreatic cancer. Further clinical investigation is needed to study the efficacy of elective treatment to CTV defined based on these patterns using high-dose conformal or intensity-modulated radiation therapy.
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Affiliation(s)
- Wenjie Sun
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Downstaging of pancreatic carcinoma after neoadjuvant chemoradiation. Strahlenther Onkol 2009; 185:557-66. [PMID: 19756421 DOI: 10.1007/s00066-009-1977-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 04/09/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Neoadjuvant chemoradiation could improve survival in patients with pancreatic cancer because of a higher rate of R0 resections, lower rate of nodal metastasis (ypN) and of local recurrence. This approach was tested in a cohort to estimate its effect on survival. PATIENTS AND METHODS Three-dimensional, conformal radiation to the primary tumor (55.8 Gy) and the lymphatics (50.4 Gy) was combined with chemotherapy. Resection was performed 6 weeks after completion of chemoradiation. RESULTS 38 of 120 patients with locally advanced cancer underwent tumor resection thereafter. Three patients (8%) had pathologic complete response. Median tumor-specific survival was 29 months and overall survival 25 months. Patients with clear margins (35/38; 89%) had a 3-year disease-specific survival rate of 51% versus 0% with positive margins (p = 0.008). Nodal disease rate decreased from 50% at pretherapeutic imaging to 32% at resection. Patients with ypN0 status (n = 26/38) had a 3-year tumor-specific survival rate of 50% compared to 31% in patients with ypN1 status. At multivariate analysis, resection status and nodal spread significantly predicted tumor-specific survival. Chemoradiation was generally well tolerated. CONCLUSION The current results support randomized testing of neoadjuvant chemoradiation to prove survival prolongation. Compared to the literature this approach seems to reduce the number of positive nodes.
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Budiharto T, Haustermans K, Van Cutsem E, Van Steenbergen W, Topal B, Aerts R, Ectors N, Bielen D, Vanbeckevoort D, Goethals L, Verslype C. A phase I radiation dose-escalation study to determine the maximal dose of radiotherapy in combination with weekly gemcitabine in patients with locally advanced pancreatic adenocarcinoma. Radiat Oncol 2008; 3:30. [PMID: 18808686 PMCID: PMC2557003 DOI: 10.1186/1748-717x-3-30] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Accepted: 09/22/2008] [Indexed: 12/05/2022] Open
Abstract
Background The primary objective of this study was to determine the maximum tolerated dose (MTD) of escalating doses of radiotherapy (RT) concomitantly with a fixed dose of gemcitabine (300 mg/m2/week) within the same overall treatment time. Methods Thirteen patients were included. Gemcitabine 300 mg/m2/week was administered prior to RT. The initial dose of RT was 45 Gy in 1.8 Gy fractions, escalated by adding 5 fractions of 1.8 Gy (one/week) to a dose of 54 Gy with a total duration kept at 5 weeks. All patients received a dynamic MRI to assess the pancreatic respiratory related movements. Toxicity was scored using the RTOG-EORTC toxicity criteria. Results Three of six patients experienced an acute dose limiting toxicity (DLT) at the 54 Gy dose level. For these patients a grade III gastro-intestinal toxicity (GI) was noted. Patients treated at the 45 Gy dose level tolerated therapy without DLT. The 54 Gy dose level was designated as the MTD and was deemed not suitable for further investigation. Between both dose levels, there was a significant difference in percentage weight loss (p = 0.006) and also in cumulative GI toxicity (p = 0.027). There was no grade 3 toxicity in the 45 Gy cohort versus 4 grade 3 toxicity events in the 54 Gy cohort. The mean dose to the duodenum was significantly higher in the 54 Gy cohort (38.45 Gy vs. 51.82 Gy; p = 0.001). Conclusion Accelerated dose escalation to a total dose of 54 Gy with 300 mg/m2/week gemcitabine was not feasible. GI toxicity was the DLT. Retrospectively, the dose escalation of 9 Gy by accelerated radiotherapy might have been to large. A dose of 45 Gy is recommended. Considering the good patient outcomes, there might be a role for the investigation of a fixed dose of gemcitabine and concurrent RT with small fractions (1.8 Gy/day) in borderline resectable or unresectable non-metastatic locally advanced pancreatic cancer.
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Affiliation(s)
- Tom Budiharto
- Department of Radiotherapy, University Hospitals Leuven, Leuven, Belgium.
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Golcher H, Brunner T, Grabenbauer G, Merkel S, Papadopoulos T, Hohenberger W, Meyer T. Preoperative chemoradiation in adenocarcinoma of the pancreas. A single centre experience advocating a new treatment strategy. Eur J Surg Oncol 2008; 34:756-64. [DOI: 10.1016/j.ejso.2007.11.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2007] [Accepted: 11/27/2007] [Indexed: 12/15/2022] Open
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Brunner TB, Geiger M, Grabenbauer GG, Lang-Welzenbach M, Mantoni TS, Cavallaro A, Sauer R, Hohenberger W, McKenna WG. Phase I trial of the human immunodeficiency virus protease inhibitor nelfinavir and chemoradiation for locally advanced pancreatic cancer. J Clin Oncol 2008; 26:2699-706. [PMID: 18509182 DOI: 10.1200/jco.2007.15.2355] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Preclinically, HIV protease inhibitors radiosensitize tumors with activated PI3-kinase/Akt pathway. We determined the toxicity of nelfinavir chemoradiotherapy in borderline resectable and unresectable pancreatic cancer. PATIENTS AND METHODS Oral nelfinavir (2 x 1,250 mg) was started 3 days before and continued throughout chemoradiotherapy to 50.4 Gy (boost, 59.4 Gy) in 12 patients. Two gemcitabine dose levels (DL) were tested (200 mg/m(2) and 300 mg/m(2) on days 1, 8, 22, and 29). Cisplatin was administered on the same days at 30 mg/m(2). Phospho-Akt downregulation by nelfinavir was monitored by immunoblotting in patient leukocytes. Restaging positron emission tomography (PET)/computed tomography (CT) and CA19-9 levels served to assess response, and responding tumors were resected. RESULTS At each DL, five of six patients completed chemoradiotherapy, and two of 12 patients had incomplete chemoradiotherapy because of clinical depression (DL1) and peritoneal metastasis (DL2). Grade 4 toxicities were a transaminase elevation (DL2) as a result of biliary stent occlusion and acute cholecystitis as a result of peritoneal metastasis (DL2). Stent occlusions led to dose-limiting toxicities of grade 3 liver enzyme and bilirubin elevations (two patients at DL1, one patient at DL2). Grade 3 nausea and vomiting occurred in a DL2 patient, and weight loss occurred in a DL1 patient who refused supportive feeding. Secondary complete resection was possible in six of 10 patients with complete chemoradiotherapy, including one tumor with pathologic sterilization. Partial CT responses were observed in five of 10 patients who completed chemoradiotherapy. Of nine patients assessable by PET,responses were complete in five patients and partial patients, and stable disease was observed in two patients. CONCLUSION The combination of nelfinavir and chemoradiotherapy showed acceptable toxicity and promising activity in patients with pancreatic cancer.
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Affiliation(s)
- Thomas B Brunner
- Gray Institute of Radiation Oncology and Biology, University of Oxford, Churchill Hospital, Oxford, United Kingdom.
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Meier I, Merkel S, Papadopoulos T, Sauer R, Hohenberger W, Brunner TB. Adenocarcinoma of the esophagogastric junction: the pattern of metastatic lymph node dissemination as a rationale for elective lymphatic target volume definition. Int J Radiat Oncol Biol Phys 2008; 70:1408-17. [PMID: 18374226 DOI: 10.1016/j.ijrobp.2007.08.053] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 08/21/2007] [Accepted: 08/21/2007] [Indexed: 01/28/2023]
Abstract
PURPOSE Regional nodal metastasis after neoadjuvant chemoradiation of adenocarcinoma of the esophagogastric junction (AEG) predicts survival. We aimed to clarify the lymph node (LN) distribution of AEG according to location of the tumor mass and invasion of neighboring areas for the selection of radiotherapy planning target volume (PTV) margins. METHODS AND MATERIALS Patterns of regional spread were analyzed in pathology reports of 326 patients patients with AEG who had undergone primary resection, with > or = 15 lymph nodes examined. Tumors were classified into AEG types based on endoscopy and pathology reports. Fisher's exact test was used to compare nodal disease and tumor characteristics. Pulmonary dose-volume histograms were tested in 8 patients. RESULTS Nodes were positive in 81% of T2 to T4 tumors. Type of AEG, tumor size, lymphovascular invasion, and grading significantly influenced nodal distribution. We found that marked esophageal invasion of AEG II/III significantly correlated with paraesophageal nodal disease, and T3 to T4 AEG II/III had a significant rate of splenic hilum/artery nodes. Middle and lower paraesophageal nodes should be treated in T2 to T4 AEG I and AEG II with > or = 15 mm involvement above the Z-line, and T3 to T4 AEG II. The splenic hilum and artery nodes can be spared in T2 AEG tumors, especially Type I tumors. The influence of paraesophageal nodal treatment on the risk of postoperative pulmonary complications can be estimated from dose-volume histograms. CONCLUSIONS Accurate pretherapeutic staging predicts the risk of subclinical nodal disease and should be used to select the appropriate radiotherapeutic PTV. Careful selection of the PTV can be used to maximize the therapeutic window in multimodal therapy for AEG.
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Affiliation(s)
- Iris Meier
- Department of Radiation Oncology, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
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Brunner TB, Grabenbauer GG, Meyer T, Golcher H, Sauer R, Hohenberger W. Primary resection versus neoadjuvant chemoradiation followed by resection for locally resectable or potentially resectable pancreatic carcinoma without distant metastasis. A multi-centre prospectively randomised phase II-study of the Interdisciplinary Working Group Gastrointestinal Tumours (AIO, ARO, and CAO). BMC Cancer 2007; 7:41. [PMID: 17338829 PMCID: PMC1821337 DOI: 10.1186/1471-2407-7-41] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Accepted: 03/06/2007] [Indexed: 12/13/2022] Open
Abstract
Background The disappointing results of surgical therapy alone of ductal pancreatic cancer can only be improved using multimodal approaches. In contrast to adjuvant therapy, neoadjuvant chemoradiation is able to facilitate resectability with free margins and to lower lymphatic spread. Another advantage is better tolerability which consecutively allows applying multimodal treatment in a higher number of patients. Furthermore, the synopsis of the overall survival results of neoadjuvant trials suggests a higher rate compared to adjuvant trials. Methods/Design As there are no prospectively randomised studies for neoadjuvant therapy, the Interdisciplinary Study Group of Gastrointestinal Tumours of the German Cancer Aid has started such a trial. The study investigates the effect of neoadjuvant chemoradiation in locally resectable or probably resectable cancer of the pancreatic head without distant metastasis on median overall survival time compared to primary surgery. Adjuvant chemotherapy is integrated into both arms. Discussion The protocol of the study is presented in condensed form after an introducing survey on adjuvant and neoadjuvant therapy in pancreatic cancer.
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Affiliation(s)
- Thomas B Brunner
- Department of Radiation Oncology of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Gerhard G Grabenbauer
- Department of Radiation Oncology of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Thomas Meyer
- Department of Surgery of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Henriette Golcher
- Department of Surgery of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Rolf Sauer
- Department of Radiation Oncology of the University at Erlangen-Nuremberg, Erlangen, Germany
| | - Werner Hohenberger
- Department of Surgery of the University at Erlangen-Nuremberg, Erlangen, Germany
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Brunner TB, Baum U, Grabenbauer GG, Sauer R, Lambrecht U. Large topographic variability of upper abdominal lymphatics and the consequences for radiation treatment planning. Radiother Oncol 2006; 81:190-5. [PMID: 17050019 DOI: 10.1016/j.radonc.2006.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Revised: 09/15/2006] [Accepted: 09/22/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE Inclusion of regional lymph nodes usually is indicated when treating upper gastrointestinal malignancies. Lymphatics follow the large vessels of this region. Vascular variability with consequences for planning treatment volume (PTV) was studied. MATERIALS AND METHODS Upper abdominal metric relationship of the vascular origins was analysed in CT scans in 104 patients to estimate its influence on PTV variability. PTV volumes were calculated based on these. Additionally, the PTV size of 3D plans of 34 patients with pancreatic adenocarcinoma (PDAC) was analysed depending on different PTV definitions. RESULTS Vascular origin varied most for the inferior mesenteric artery (IMA) with substantial PTV size differences. Volumetric variability was analysed for PDAC (IMA versus renal hilum as caudal margin). Additional PTV for IMA was < 100 cc (median) but ranged up to 350 cc in CT (100-199 ml in 14/34 and > 200 ml in 3/34 patients). Data from treatment planning confirmed this observation. CONCLUSIONS Considerable vascular and lymphatic variability obliges to base PTV on the individual vascular anatomy. For most patients the caudal PTV margin for PDAC can safely be set at the IMA. But PTV should be restricted when the additional volume would lead to a significant increase to avoid haematotoxicity from concomitant gemcitabine which is proportional with PTV size. The risk of kidney toxicity is also subject to PTV expansion in the caudal direction.
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Affiliation(s)
- Thomas B Brunner
- Department of Radiation Oncology, University Hospitals of Erlangen, Erlangen, Germany.
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