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Kobeissi JM, Simone CB, Lin H, Hilal L, Hajj C. Proton Therapy in the Management of Pancreatic Cancer. Cancers (Basel) 2022; 14:cancers14112789. [PMID: 35681769 PMCID: PMC9179382 DOI: 10.3390/cancers14112789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Radiation treatment plays a pivotal a role in the management of pancreatic cancer, mainly in the neoadjuvant setting for borderline resectable tumors and in the definitive setting for unresectable localized disease. Most of the studies on pancreatic cancer use photon-based radiation therapy modalities. However, there is a growing interest in the application of protons therapy for gastrointestinal cancers. This review summarizes the literature on the use of proton therapy in the management of pancreatic cancer. Abstract Radiation therapy plays a central role in the treatment of pancreatic cancer. While generally shown to be feasible, proton irradiation, particularly when an ablative dose is planned, remains a challenge, especially due to tumor motion and the proximity to organs at risk, like the stomach, duodenum, and bowel. Clinically, standard doses of proton radiation treatment have not been shown to be statistically different from photon radiation treatment in terms of oncologic outcomes and toxicity rates as per non-randomized comparative studies. Fractionation schedules and concurrent chemotherapy combinations are yet to be optimized for proton therapy and are the subject of ongoing trials.
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Affiliation(s)
- Jana M. Kobeissi
- Department of Radiation Oncology, School of Medicine, American University of Beirut Medical Center, Beirut 1107, Lebanon; (J.M.K.); (L.H.)
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (C.B.S.II); (H.L.)
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA
| | - Haibo Lin
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (C.B.S.II); (H.L.)
| | - Lara Hilal
- Department of Radiation Oncology, School of Medicine, American University of Beirut Medical Center, Beirut 1107, Lebanon; (J.M.K.); (L.H.)
| | - Carla Hajj
- Department of Radiation Oncology, New York Proton Center, New York, NY 10035, USA; (C.B.S.II); (H.L.)
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA
- Correspondence:
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Efficacy and feasibility of proton beam radiotherapy using the simultaneous integrated boost technique for locally advanced pancreatic cancer. Sci Rep 2020; 10:21712. [PMID: 33303947 PMCID: PMC7729854 DOI: 10.1038/s41598-020-78875-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/01/2020] [Indexed: 01/05/2023] Open
Abstract
To evaluate the clinical efficacy and feasibility of proton beam radiotherapy (PBT) using the simultaneous integrated boost (SIB) technique in locally advanced pancreatic cancer (LAPC), 81 LAPC patients receiving PBT using SIB technique were analyzed. The prescribed doses to planning target volume (PTV)1 and PTV2 were 45 or 50 GyE and 30 GyE in 10 fractions, respectively. Of 81 patients, 18 patients received PBT without upfront and maintenance chemotherapy (group I), 44 received PBT followed by maintenance chemotherapy (group II), and 19 received PBT after upfront chemotherapy followed by maintenance chemotherapy (n = 16) (group III). The median follow-up time was 19.6 months (range 2.3-57.6 months), and the median overall survival (OS) times of all patients and of those in groups I, II, and III were 19.3 months (95% confidence interval [CI] 16.8-21.7 months), 15.3 months (95% CI 12.9-17.7 months), 18.3 months (95% CI 15.9-20.7 months), and 26.1 months (95% CI 17.8-34.3 months), respectively (p = 0.043). Acute and late grade ≥ 3 toxicities related to PBT were not observed. PBT with the SIB technique showed promising OS for LAPC patients with a safe toxicity profile, and intensive combinations of PBT and chemotherapy could improve OS in these patients.
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Raturi VP, Tochinai T, Hojo H, Rachi T, Hotta K, Nakamura N, Zenda S, Motegi A, Ariji T, Hirano Y, Baba H, Ohyoshi H, Nakamura M, Okumura M, Bei Y, Akimoto T. Dose-Volume and Radiobiological Model-Based Comparative Evaluation of the Gastrointestinal Toxicity Risk of Photon and Proton Irradiation Plans in Localized Pancreatic Cancer Without Distant Metastasis. Front Oncol 2020; 10:517061. [PMID: 33194580 PMCID: PMC7645056 DOI: 10.3389/fonc.2020.517061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 09/01/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Radiobiological model-based studies of photon-modulated radiotherapy for pancreatic cancer have reported reduced gastrointestinal (GI) toxicity, although the risk is still high. The purpose of this study was to investigate the potential of 3D-passive scattering proton beam therapy (3D-PSPBT) in limiting GI organ at risk (OAR) toxicity in localized pancreatic cancer based on dosimetric data and the normal tissue complication probability (NTCP) model. Methods: The data of 24 pancreatic cancer patients were retrospectively analyzed, and these patients were planned with intensity-modulated radiotherapy (IMRT), volume-modulated arc therapy (VMAT), and 3D-PSPBT. The tumor was targeted without elective nodal coverage. All generated plans consisted of a 50.4-GyE (Gray equivalent) dose in 28 fractions with equivalent OAR constraints, and they were normalized to cover 50% of the planning treatment volume (PTV) with 100% of the prescription dose. Physical dose distributions were evaluated. GI-OAR toxicity risk for different endpoints was estimated by using published NTCP Lyman-Kutcher-Burman (LKB) models. Analysis of variance (ANOVA) was performed to compare the dosimetric data, and ΔNTCPIMRT-PSPBT and ΔNTCPVMAT-PSPBT were also computed. Results: Similar homogeneity and conformity for the clinical target volume (CTV) and PTV were exhibited by all three planning techniques (P > 0.05). 3D-PSPBT resulted in a significant dose reduction for GI-OARs in both the low-intermediate dose range (below 30 GyE) and the highest dose region (D max and V 50 GyE) in comparison with IMRT and VMAT (P < 0.05). Based on the NTCP evaluation, the NTCP reduction for GI-OARs by 3D-PSPBT was minimal in comparison with IMRT and VMAT. Conclusion: 3D-PSPBT results in minimal NTCP reduction and has less potential to substantially reduce the toxicity risk of upper GI bleeding, ulceration, obstruction, and perforation endpoints compared to IMRT and VMAT. 3D-PSPBT may have the potential to reduce acute dose-limiting toxicity in the form of nausea, vomiting, and diarrhea by reducing the GI-OAR treated volume in the low-to-intermediate dose range. However, this result needs to be further evaluated in future clinical studies.
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Affiliation(s)
- Vijay P. Raturi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
- Course of Advanced Clinical Research of Cancer, Graduate School of Medicine, Juntendo University, Tokyo, Japan
- *Correspondence: Vijay P. Raturi
| | - Taku Tochinai
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Hidehiro Hojo
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Toshiya Rachi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Kenji Hotta
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Sadamoto Zenda
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Atsushi Motegi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Takaki Ariji
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Yasuhiro Hirano
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Hiromi Baba
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Hajime Ohyoshi
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Masaki Nakamura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Masayuki Okumura
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Yanping Bei
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital, Chiba, Japan
- Course of Advanced Clinical Research of Cancer, Graduate School of Medicine, Juntendo University, Tokyo, Japan
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Koom WS, Mori S, Furuich W, Yamada S. Beam direction arrangement using a superconducting rotating gantry in carbon ion treatment for pancreatic cancer. Br J Radiol 2019; 92:20190101. [PMID: 30943057 DOI: 10.1259/bjr.20190101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Carbon ion radiotherapy provides a concentrated dose distribution to the target and has several advantages over photon radiotherapy. This study aimed to evaluate the optimal beam direction in carbon ion pencil beam scanning and compare dose distributions between the rotating gantry system (RGS) and fixed-beam port system (FBPS). METHODS Patients with locally advanced pancreatic cancer were randomly selected. First, dose-volume parameters of 7-beam directions in the prone position were evaluated. Second, a composite plan developed using 4-beam directions in RGS was compared with that developed using FBPS, with a total prescribed dose of 55.2 Gy (relative biological effectiveness, RBE) in 12 fractions. RESULTS Target coverages in the composite plan did not widely differ. For the first and second segments of the duodenum, the mean dose of D2cc was not significantly changed (23.80 ± 11.90 Gy [RBE] and 25.63 ± 10.41 Gy [RBE] for RGS and FBPS, respectively). However, the dose-volume histogram curve in RGS showed a prominent dose reduction in the low-dose region. No significant differences were observed in the stomach, third and fourth segments of the duodenum, and spinal cord. The mean dose of the total kidney was similar between RGS and FBPS. CONCLUSIONS Compared with that of FBPS, the 4-beam arrangement in the prone position using RGS provides comparable or superior dose distribution in the surrounding normal organ while achieving the same target coverage. In addition, RGS allows for single-patient positioning. ADVANCES IN KNOWLEDGE RGS is beneficial in delivering radiotherapy doses to the duodenum and allows for single-patient positioning and a simple planning process.
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Affiliation(s)
- Woong Sub Koom
- 1 Department of Radiation Oncology, Yonsei University College of Medicine , Seoul , South Korea.,2 Research Center for Charged Particle Therapy, National Institute of Radiological Sciences , Chiba , Japan
| | - Shinichiro Mori
- 2 Research Center for Charged Particle Therapy, National Institute of Radiological Sciences , Chiba , Japan
| | | | - Shigeru Yamada
- 2 Research Center for Charged Particle Therapy, National Institute of Radiological Sciences , Chiba , Japan
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Nakamura A, Prichard HA, Wo JY, Wolfgang JA, Hong TS. Elective nodal irradiation with simultaneous integrated boost stereotactic body radiotherapy for pancreatic cancer: Analyses of planning feasibility and geometrically driven DVH prediction model. J Appl Clin Med Phys 2019; 20:71-83. [PMID: 30636367 PMCID: PMC6370996 DOI: 10.1002/acm2.12528] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 12/05/2018] [Accepted: 12/14/2018] [Indexed: 12/31/2022] Open
Abstract
PURPOSE We evaluate the feasibility of the elective nodal irradiation strategy in stereotactic body radiotherapy (SBRT) for pancreatic cancer. METHODS Three simultaneous integrated boost (SIB)-SBRT plans (Boost1, Boost2, and Boost3) were retrospectively generated for each of 20 different patients. Boost1 delivered 33 and 25 Gy to PTV1 and PTV2, respectively. Boost2 delivered 40, 33, and 25 Gy to boostCTV, PTV1, and PTV2, respectively. Boost3 delivered 33 and 25 Gy to PTV1 and PTV3, respectively. PTV1 covered the initial standard SBRT plan (InitPlan) gross tumor volume (GTV). PTV2 covered CTVgeom which was created by a 10-mm expansion (15 mm posterior) of GTV. PTV3 covered CTVprop which included elective nodal regions. The boostCTV included GTV as well as involved vasculature. The planning feasibility in each scenario and dose-volume histograms (DVHs) were analyzed and compared with the InitPlan (delivered 33 Gy only to PTV1) by paired t-test. Next, a novel DVH prediction model was developed and its performance was evaluated according to the prediction accuracy (AC) of planning violations. Then, the model was used to simulate the impacts of GTV-to-organs at risk (OAR) distance and gastrointestinal (GI) OAR volume variations on planning feasibility. RESULTS Significant dose increases were observed in GI-OARs in SIB-SBRT plans when compared with InitPlan. All dose constraints were met in 63% of cases in InitPlan, Boost1, and Boost2, whereas Boost3 developed DVH violations in all cases. Utilizing previous patient anatomy, the novel DVH prediction model achieved a high AC in the prediction of violations for GI-OARs; the positive predictive value, negative predictive value, and AC were 66%, 90%, and 84%, respectively. Experiments with the model demonstrated that the larger proximity volume of GI-OAR at the shorter distance substantially impacted on planning violations. CONCLUSIONS SIB-SBRT plan with geometrically defined prophylactic areas can be dosimetrically feasible, but including all nodal areas with 25 Gy in five fractions appears to be unrealistic.
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Affiliation(s)
- Akira Nakamura
- Department of Radiation OncologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Hugh A. Prichard
- Department of Radiation OncologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Jennifer Y. Wo
- Department of Radiation OncologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - John A. Wolfgang
- Department of Radiation OncologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Theodore S. Hong
- Department of Radiation OncologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
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Kim TH, Lee WJ, Woo SM, Kim H, Oh ES, Lee JH, Han SS, Park SJ, Suh YG, Moon SH, Kim SS, Kim DY. Effectiveness and Safety of Simultaneous Integrated Boost-Proton Beam Therapy for Localized Pancreatic Cancer. Technol Cancer Res Treat 2018; 17:1533033818783879. [PMID: 29962281 PMCID: PMC6048612 DOI: 10.1177/1533033818783879] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Purpose: To evaluate the clinical effectiveness and feasibility of simultaneous integrated
boost-proton beam therapy in patients with localized pancreatic cancer. Methods: Thirty-seven patients with localized pancreatic cancer underwent simultaneous
integrated boost-proton beam therapy, and 8 (21.6%) patients received induction
chemotherapy. The internal target volume was obtained by summing the gross tumor volumes
in exhalation phase computed tomography images. Planning target volume 1 included
internal target volume plus 3 to 5 mm margins, excluding the 5 mm expanded volume of
gastrointestinal structures, and planning target volume 2 included the internal target
volume plus 7 to 12 mm margins. The prescribed doses to planning target volume 1 and
planning target volume 2 were 45 GyE (equivalent dose in 2 Gy, 54.4 GyE10)
and 30 GyE (equivalent dose in 2 Gy, 32.5 GyE10) in 10 fractions,
respectively. Results: Overall, treatment was well tolerated, with no grade of toxicity ≥3. Median overall
survival was 19.3 months, and 1-year local progression-free survival, relapse-free
survival, and overall survival rates were 64.8%, 33.2%, and 75.7%, respectively.
Patients treated with simultaneous integrated boost-proton beam therapy after induction
chemotherapy had a significantly higher median overall survival time compared to those
with simultaneous integrated boost-proton beam therapy alone (21.6 months vs 16.7
months, P = .031). Multivariate analysis showed that induction
chemotherapy was a significant factor for overall survival (P <
.05). Conclusions: Simultaneous integrated boost-proton beam therapy could be feasible and promising for
patients with localized pancreatic cancer.
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Affiliation(s)
- Tae Hyun Kim
- 1 Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea.,2 Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Woo Jin Lee
- 1 Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sang Myung Woo
- 1 Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Hyunjung Kim
- 2 Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Eun Sang Oh
- 2 Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Ju Hee Lee
- 1 Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sung-Sik Han
- 1 Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sang-Jae Park
- 1 Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Yang-Gun Suh
- 2 Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sung Ho Moon
- 2 Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Sang Soo Kim
- 2 Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Dae Yong Kim
- 2 Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
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Stefanowicz S, Stützer K, Zschaeck S, Jakobi A, Troost EGC. Comparison of different treatment planning approaches for intensity-modulated proton therapy with simultaneous integrated boost for pancreatic cancer. Radiat Oncol 2018; 13:228. [PMID: 30466468 PMCID: PMC6249773 DOI: 10.1186/s13014-018-1165-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/30/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Neoadjuvant radio(chemo)therapy of non-metastasized, borderline resectable or unresectable locally advanced pancreatic cancer is complex and prone to cause side-effects, e.g., in gastrointestinal organs. Intensity-modulated proton therapy (IMPT) enables a high conformity to the targets while simultaneously sparing the normal tissue such that dose-escalation strategies come within reach. In this in silico feasibility study, we compared four IMPT planning strategies including robust multi-field optimization (rMFO) and a simultaneous integrated boost (SIB) for dose-escalation in pancreatic cancer patients. METHODS For six pancreatic cancer patients referred for adjuvant or primary radiochemotherapy, four rMFO-IMPT-SIB treatment plans each, consisting of two or three (non-)coplanar beam arrangements, were optimized. Dose values for both targets, i.e., the elective clinical target volume [CTV, prescribed dose Dpres = 51Gy(RBE)] and the boost target [Dpres = 66Gy(RBE)], for the organs at risk as well as target conformity and homogeneity indexes, derived from the dose volume histograms, were statistically compared. RESULTS All treatment plans of each strategy fulfilled the prescribed doses to the targets (Dpres(GTV,CTV) = 100%, D95%,(GTV,CTV) ≥ 95%, D2%,(GTV,CTV) ≤ 107%). No significant differences for the conformity index were found (p > 0.05), however, treatment plans with a three non-coplanar beam strategy were most homogenous to both targets (p < 0.045). The median value of all dosimetric results of the large and small bowel as well as for the liver and the spinal cord met the dose constraints with all beam arrangements. Irrespective of the planning strategies, the dose constraint for the duodenum and stomach were not met. Using the three-beam arrangements, the dose to the left kidney could be significant decreased when compared to a two-beam strategy (p < 0.045). CONCLUSION Based on our findings we recommend a three-beam configuration with at least one non-coplanar beam for dose-escalated SIB with rMFO-IMPT in advanced pancreatic cancer patients achieving a homogeneous dose distribution in the target while simultaneously minimizing the dose to the organs at risk. Further treatment planning studies on aspects of breathing and organ motion need to be performed.
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Affiliation(s)
- Sarah Stefanowicz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Kristin Stützer
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Sebastian Zschaeck
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Annika Jakobi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany. .,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany. .,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany. .,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
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Simulation study of dosimetric effect in proton beam therapy using concomitant boost technique for unresectable pancreatic cancers. Jpn J Radiol 2018; 36:456-461. [DOI: 10.1007/s11604-018-0743-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/06/2018] [Indexed: 12/25/2022]
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9
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Jethwa KR, Tryggestad EJ, Whitaker TJ, Giffey BT, Kazemba BD, Neben-Wittich MA, Merrell KW, Haddock MG, Hallemeier CL. Initial experience with intensity modulated proton therapy for intact, clinically localized pancreas cancer: Clinical implementation, dosimetric analysis, acute treatment-related adverse events, and patient-reported outcomes. Adv Radiat Oncol 2018; 3:314-321. [PMID: 30202800 PMCID: PMC6128024 DOI: 10.1016/j.adro.2018.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/25/2018] [Accepted: 04/04/2018] [Indexed: 12/22/2022] Open
Abstract
Purpose Pencil-beam scanning intensity modulated proton therapy (IMPT) may allow for an improvement in the therapeutic ratio compared with conventional techniques of radiation therapy delivery for pancreatic cancer. The purpose of this study was to describe the clinical implementation of IMPT for intact and clinically localized pancreatic cancer, perform a matched dosimetric comparison with volumetric modulated arc therapy (VMAT), and report acute adverse event (AE) rates and patient-reported outcomes (PROs) of health-related quality of life. Methods and materials Between July 2016 and March 2017, 13 patients with localized pancreatic cancer underwent concurrent capecitabine or 5-fluorouracil-based chemoradiation therapy (CRT) utilizing IMPT to a dose of 50 Gy (radiobiological effectiveness: 1.1). A VMAT plan was generated for each patient to use for dosimetric comparison. Patients were assessed prospectively for AEs and completed PRO questionnaires utilizing the Functional Assessment of Cancer Therapy-Hepatobiliary at baseline and upon completion of CRT. Results There was no difference in mean target coverage between IMPT and VMAT (P > .05). IMPT offered significant reductions in dose to organs at risk, including the small bowel, duodenum, stomach, large bowel, liver, and kidneys (P < .05). All patients completed treatment without radiation therapy breaks. The median weight loss during treatment was 1.6 kg (range, 0.1-5.7 kg). No patients experienced grade ≥3 treatment-related AEs. The median Functional Assessment of Cancer Therapy-Hepatobiliary scores prior to versus at the end of CRT were 142 (range, 113-163) versus 136 (range, 107-173; P = .18). Conclusions Pencil-beam scanning IMPT was feasible and offered significant reductions in radiation exposure to multiple gastrointestinal organs at risk. IMPT was associated with no grade ≥3 gastrointestinal AEs and no change in baseline PROs, but the conclusions are limited due to the patient sample size. Further clinical studies are warranted to evaluate whether these dosimetric advantages translate into clinically meaningful benefits.
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Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Broc T Giffey
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bret D Kazemba
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Mondlane G, Gubanski M, Lind PA, Ureba A, Siegbahn A. Comparison of gastric-cancer radiotherapy performed with volumetric modulated arc therapy or single-field uniform-dose proton therapy. Acta Oncol 2017; 56:832-838. [PMID: 28281357 DOI: 10.1080/0284186x.2017.1297536] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Proton-beam therapy of large abdominal cancers has been questioned due to the large variations in tissue density in the abdomen. The aim of this study was to evaluate the importance of these variations for the dose distributions produced in adjuvant radiotherapy of gastric cancer (GC), implemented with photon-based volumetric modulated arc therapy (VMAT) or with proton-beam single-field uniform-dose (SFUD) method. MATERIAL AND METHODS Eight GC patients were included in this study. For each patient, a VMAT- and an SFUD-plan were created. The prescription dose was 45 Gy (IsoE) given in 25 fractions. The plans were prepared on the original CT studies and the doses were thereafter recalculated on two modified CT studies (one with extra water filling and the other with expanded abdominal air-cavity volumes). RESULTS Compared to the original VMAT plans, the SFUD plans resulted in reduced median values for the V18 of the left kidney (26%), the liver mean dose (14.8 Gy (IsoE)) and the maximum dose given to the spinal cord (26.6 Gy (IsoE)). However, the PTV coverage decreased when the SFUD plans were recalculated on CT sets with extra air- (86%) and water-filling (87%). The added water filling only led to minor dosimetric changes for the OARs, but the extra air caused significant increases of the median values of V18 for the right and left kidneys (10% and 12%, respectively) and of V10 for the liver (12%). The density changes influenced the dose distributions in the VMAT plans to a minor extent. CONCLUSIONS SFUD was found to be superior to VMAT for the plans prepared on the original CT sets. However, SFUD was inferior to VMAT for the modified CT sets.
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Affiliation(s)
- Gracinda Mondlane
- Department of Physics – Medical Radiation Physics, Stockholm University, Stockholm, Sweden
- Department of Physics, Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Michael Gubanski
- Department of Oncology and Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - Pehr A. Lind
- Department of Oncology and Pathology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology, Södersjukhuset, Stockholm, Sweden
| | - Ana Ureba
- Department of Physics – Medical Radiation Physics, Stockholm University, Stockholm, Sweden
| | - Albert Siegbahn
- Department of Physics – Medical Radiation Physics, Stockholm University, Stockholm, Sweden
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11
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The Role of Radiation Therapy for Pancreatic Cancer in the Adjuvant and Neoadjuvant Settings. Surg Oncol Clin N Am 2017; 26:431-453. [PMID: 28576181 DOI: 10.1016/j.soc.2017.01.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer is the third leading cause of cancer-related death in the United States. Although surgery remains the only curative treatment, chemotherapy and radiation therapy are frequently used. In the adjuvant setting, radiation is usually delivered with chemotherapy to eradicate residual microscopic or macroscopic disease in the resection bed. Neoadjuvant radiation therapy has become more frequently utilized. This article reviews the historical and modern literature regarding radiation therapy in the neoadjuvant and adjuvant settings, focusing on the evolution of radiation therapy techniques and clinical trials in an attempt to identify patients best suited to receiving radiation therapy.
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12
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Miki K, Fukahori M, Kumagai M, Yamada S, Mori S. Effect of patient positioning on carbon-ion therapy planned dose distribution to pancreatic tumors and organs at risk. Phys Med 2017; 33:38-46. [DOI: 10.1016/j.ejmp.2016.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/17/2016] [Accepted: 12/04/2016] [Indexed: 11/25/2022] Open
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13
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Popp I, Grosu AL, Niedermann G, Duda DG. Immune modulation by hypofractionated stereotactic radiation therapy: Therapeutic implications. Radiother Oncol 2016; 120:185-94. [PMID: 27495145 DOI: 10.1016/j.radonc.2016.07.013] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 05/17/2016] [Accepted: 07/07/2016] [Indexed: 02/06/2023]
Abstract
Stereotactic body radiation therapy (SBRT) has become an attractive treatment modality and a safe, non-invasive alternative to surgery to control primary or secondary malignant tumors. While emphasis has been on the local tumor control as a treatment objective for SBRT, the rare but intriguing observations of abscopal (or out-of-field) effects have pointed to the exciting possibility of activating anti-tumor immunity by using high-dose radiation. This review summarizes the available evidence supporting immune modulation by SBRT alone, as well as its potential combination with immunotherapy. Promising preclinical research has revealed an array of immune changes following SBRT, which could affect the balance between anti-tumor immunity and tumor-promoting immunosuppression. However, shifting this balance in the clinical setting to obtain survival benefits has rarely been achieved so far, emphasizing the need for a better understanding of the interactions between high-dose radiotherapy and immunity or immunotherapy. Nevertheless, the combination of SBRT with immunotherapy, particularly with immune checkpoint blockers, has the clear potential to substantially increase the rate of abscopal effects. This warrants further research in this area, both in mechanistic preclinical studies and in clinical trials incorporating correlative studies.
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Affiliation(s)
- Ilinca Popp
- Department of Radiation Oncology, University Medical Center Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
| | - Anca Ligia Grosu
- Department of Radiation Oncology, University Medical Center Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
| | - Gabriele Niedermann
- Department of Radiation Oncology, University Medical Center Freiburg, Germany; German Cancer Consortium (DKTK), Partner Site Freiburg, Germany
| | - Dan G Duda
- Steele Laboratories, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, USA.
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14
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Alexander C, Crumley C, Ho P. Proton Use in Radiotherapy: Superior Treatment or Flavour of the Month-An Overview. J Med Imaging Radiat Sci 2016; 47:9-12. [PMID: 31047169 DOI: 10.1016/j.jmir.2015.12.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Catherine Crumley
- British Columbia Cancer Agency Vancouver Centre, British Columbia, Canada
| | - Patricia Ho
- British Columbia Cancer Agency Vancouver Centre, British Columbia, Canada
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15
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Spot-scanned pancreatic stereotactic body proton therapy: A dosimetric feasibility and robustness study. Phys Med 2016; 32:331-42. [DOI: 10.1016/j.ejmp.2015.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/15/2015] [Accepted: 12/27/2015] [Indexed: 12/31/2022] Open
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16
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Thompson RF, Mayekar SU, Zhai H, Both S, Apisarnthanarax S, Metz JM, Plastaras JP, Ben-Josef E. A dosimetric comparison of proton and photon therapy in unresectable cancers of the head of pancreas. Med Phys 2015; 41:081711. [PMID: 25086521 DOI: 10.1118/1.4887797] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Uncontrolled local growth is the cause of death in ∼ 30% of patients with unresectable pancreatic cancers. The addition of standard-dose radiotherapy to gemcitabine has been shown to confer a modest survival benefit in this population. Radiation dose escalation with three-dimensional planning is not feasible, but high-dose intensity-modulated radiation therapy (IMRT) has been shown to improve local control. Still, dose-escalation remains limited by gastrointestinal toxicity. In this study, the authors investigate the potential use of double scattering (DS) and pencil beam scanning (PBS) proton therapy in limiting dose to critical organs at risk. METHODS The authors compared DS, PBS, and IMRT plans in 13 patients with unresectable cancer of the pancreatic head, paying particular attention to duodenum, small intestine, stomach, liver, kidney, and cord constraints in addition to target volume coverage. All plans were calculated to 5500 cGy in 25 fractions with equivalent constraints and normalized to prescription dose. All statistics were by two-tailed paired t-test. RESULTS Both DS and PBS decreased stomach, duodenum, and small bowel dose in low-dose regions compared to IMRT (p < 0.01). However, protons yielded increased doses in the mid to high dose regions (e.g., 23.6-53.8 and 34.9-52.4 Gy for duodenum using DS and PBS, respectively; p < 0.05). Protons also increased generalized equivalent uniform dose to duodenum and stomach, however these differences were small (<5% and 10%, respectively; p < 0.01). Doses to other organs-at-risk were within institutional constraints and placed no obvious limitations on treatment planning. CONCLUSIONS Proton therapy does not appear to reduce OAR volumes receiving high dose. Protons are able to reduce the treated volume receiving low-intermediate doses, however the clinical significance of this remains to be determined in future investigations.
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Affiliation(s)
- Reid F Thompson
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Sonal U Mayekar
- Thomas Jefferson University, Philadelphia, Pennsylvania 19107
| | - Huifang Zhai
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Stefan Both
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | | | - James M Metz
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | | | - Edgar Ben-Josef
- University of Pennsylvania, Philadelphia, Pennsylvania 19104
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17
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Individualized radiotherapy (iRT) concepts for locally advanced pancreatic cancer (LAPC): indications and prognostic factors. Langenbecks Arch Surg 2015; 400:749-56. [DOI: 10.1007/s00423-015-1309-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 05/26/2015] [Indexed: 12/25/2022]
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18
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Ling TC, Slater JM, Mifflin R, Nookala P, Grove R, Ly AM, Patyal B, Slater JD, Yang GY. Evaluation of normal tissue exposure in patients receiving radiotherapy for pancreatic cancer based on RTOG 0848. J Gastrointest Oncol 2015; 6:108-14. [PMID: 25830030 DOI: 10.3978/j.issn.2078-6891.2014.094] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 10/29/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Pancreatic cancer is a highly aggressive malignancy. Chemoradiotherapy (CRT) is utilized in many cases to improve locoregional control; however, toxicities associated with radiation can be significant given the location of the pancreas. RTOG 0848 seeks to evaluate chemoradiation using either intensity-modulated radiation therapy (IMRT) or 3D conformal photon radiotherapy (3DCRT) modalities as an adjuvant treatment. The purpose of this study is to quantify the dosimetric changes seen when using IMRT or 3D CRT photon modalities, as well as proton radiotherapy, in patients receiving CRT for cancer of the pancreas treated per RTOG 0848 guidelines. MATERIALS Ten patients with pancreatic head adenocarcinoma treated between 2010 and 2013 were evaluated in this study. All patients were simulated with contrast-enhanced CT imaging. Separate treatment plans using IMRT and 3DCRT as well as proton radiotherapy were created for each patient. All planning volumes were created per RTOG 0848 protocol. Dose-volume histograms (DVH) were calculated and analyzed in order to compare plans between the three modalities. The organs at risk (OAR) evaluated in this study are the kidneys, liver, small bowel, and spinal cord. RESULTS There was no difference between the IMRT and 3DCRT plans in dose delivered to the kidneys, liver, or bowel. The proton radiotherapy plans were found to deliver lower mean total kidney doses, mean liver doses, and liver D1/3 compared to the IMRT plans. The proton plans also gave less mean liver dose, liver D1/3, bowel V15, and bowel V50 in comparison to the 3DCRT. CONCLUSIONS For patients receiving radiotherapy per ongoing RTOG 0848 for pancreatic cancer, there was no significant difference in normal tissue sparing between IMRT and 3DCRT treatment planning. Therefore, the choice between the two modalities should not be a confounding factor in this study. The proton plans also demonstrated improved OAR sparing compared to both IMRT and 3DCRT treatment plans.
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Affiliation(s)
- Ted C Ling
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Jerry M Slater
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Rachel Mifflin
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Prashanth Nookala
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Roger Grove
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Anh M Ly
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Baldev Patyal
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Jerry D Slater
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Gary Y Yang
- Department of Radiation Medicine, Loma Linda University Medical Center, Loma Linda, California, USA
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19
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Slater JM, Ling TC, Mifflin R, Nookala P, Grove R, Ly AM, Patyal B, Slater JD, Yang GY. Protons Offer Reduced Tissue Exposure for Patients Receiving Radiation Therapy for Pancreatic Cancer. Int J Part Ther 2014. [DOI: 10.14338/ijpt-14-00008.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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20
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Sachsman S, Nichols RC, Morris CG, Zaiden R, Johnson EA, Awad Z, Bose D, Ho MW, Huh SN, Li Z, Kelly P, Hoppe BS. Proton Therapy and Concomitant Capecitabine for Non-Metastatic Unresectable Pancreatic Adenocarcinoma. Int J Part Ther 2014. [DOI: 10.14338/ijpt.14-00006.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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21
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Hoffe S, Rao N, Shridhar R. Neoadjuvant vs adjuvant therapy for resectable pancreatic cancer: the evolving role of radiation. Semin Radiat Oncol 2014; 24:113-25. [PMID: 24635868 DOI: 10.1016/j.semradonc.2013.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A major challenge with pancreatic cancer management is in the discrimination of clearly resectable tumors from those that would likely be accompanied by a positive resection margin if upfront surgery was attempted. The standard of care for clearly resectable pancreatic cancer remains surgery followed by adjuvant therapy, but there is considerable controversy over whether such therapeutic adjuvant strategies should include radiotherapy. Furthermore, in a malignancy with such high rates of distant metastasis, investigators are now exploring the feasibility and outcomes of delivering therapy in the neoadjuvant setting, both for clearly resectable as well as borderline resectable tumors. In this review, we explore the current standard of care of upfront surgery for clearly resectable cancers followed by adjuvant therapy, focusing on the role of radiotherapy. We highlight the difficulties in interpreting a literature fraught with inconsistencies in how resectable vs borderline resectable cancers are defined and treated. Finally, we explore the role of neoadjuvant strategies in the modern era.
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Affiliation(s)
- Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL.
| | - Nikhil Rao
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
| | - Ravi Shridhar
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
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22
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Hong TS, Ryan DP, Borger DR, Blaszkowsky LS, Yeap BY, Ancukiewicz M, Deshpande V, Shinagare S, Wo JY, Boucher Y, Wadlow RC, Kwak EL, Allen JN, Clark JW, Zhu AX, Ferrone CR, Mamon HJ, Adams J, Winrich B, Grillo T, Jain RK, DeLaney TF, Fernandez-del Castillo C, Duda DG. A phase 1/2 and biomarker study of preoperative short course chemoradiation with proton beam therapy and capecitabine followed by early surgery for resectable pancreatic ductal adenocarcinoma. Int J Radiat Oncol Biol Phys 2014; 89:830-8. [PMID: 24867540 PMCID: PMC4791180 DOI: 10.1016/j.ijrobp.2014.03.034] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 03/10/2014] [Accepted: 03/21/2014] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the safety, efficacy and biomarkers of short-course proton beam radiation and capecitabine, followed by pancreaticoduodenectomy in a phase 1/2 study in pancreatic ductal adenocarcinoma (PDAC) patients. METHODS AND MATERIALS Patients with radiographically resectable, biopsy-proven PDAC were treated with neoadjuvant short-course (2-week) proton-based radiation with capecitabine, followed by surgery and adjuvant gemcitabine. The primary objective was to demonstrate a rate of toxicity grade ≥ 3 of <20%. Exploratory biomarker studies were performed using surgical specimen tissues and peripheral blood. RESULTS The phase 2 dose was established at 5 daily doses of 5 GyE. Fifty patients were enrolled, of whom 35 patients were treated in the phase 2 portion. There were no grade 4 or 5 toxicities, and only 2 of 35 patients (4.1%) experienced a grade 3 toxicity event (chest wall pain grade 1, colitis grade 1). Of 48 patients eligible for analysis, 37 underwent pancreaticoduodenectomy. Thirty of 37 (81%) had positive nodes. Locoregional failure occurred in 6 of 37 resected patients (16.2%), and distant recurrence occurred in 35 of 48 patients (72.9%). With median follow-up of 38 months, the median progression-free survival for the entire group was 10 months, and overall survival was 17 months. Biomarker studies showed significant associations between worse survival outcomes and the KRAS point mutation change from glycine to aspartic acid at position 12, stromal CXCR7 expression, and circulating biomarkers CEA, CA19-9, and HGF (all, P<.05). CONCLUSIONS This study met the primary endpoint by showing a rate of 4.1% grade 3 toxicity for neoadjuvant short-course proton-based chemoradiation. Treatment was associated with favorable local control. In exploratory analyses, KRAS(G12D) status and high CXCR7 expression and circulating CEA, CA19-9, and HGF levels were associated with poor survival.
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MESH Headings
- Aged
- Aged, 80 and over
- Antimetabolites, Antineoplastic/therapeutic use
- Biomarkers, Tumor/analysis
- CA-19-9 Antigen/blood
- Capecitabine
- Carcinoembryonic Antigen/blood
- Carcinoma, Pancreatic Ductal/blood
- Carcinoma, Pancreatic Ductal/chemistry
- Carcinoma, Pancreatic Ductal/mortality
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/therapy
- Chemoradiotherapy, Adjuvant/methods
- Chemoradiotherapy, Adjuvant/mortality
- Deoxycytidine/analogs & derivatives
- Deoxycytidine/therapeutic use
- Female
- Fluorouracil/analogs & derivatives
- Fluorouracil/therapeutic use
- Genes, ras/genetics
- Hepatocyte Growth Factor/blood
- Humans
- Male
- Middle Aged
- Pancreatic Neoplasms/blood
- Pancreatic Neoplasms/chemistry
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/therapy
- Pancreaticoduodenectomy
- Prognosis
- Prospective Studies
- Proto-Oncogene Proteins/analysis
- Proto-Oncogene Proteins p21(ras)
- Proton Therapy/methods
- Receptors, CXCR/analysis
- ras Proteins/analysis
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Affiliation(s)
- Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - David P Ryan
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Darrell R Borger
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lawrence S Blaszkowsky
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marek Ancukiewicz
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Vikram Deshpande
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Shweta Shinagare
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yves Boucher
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Raymond C Wadlow
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eunice L Kwak
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jill N Allen
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew X Zhu
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Harvey J Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Judith Adams
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Barbara Winrich
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tarin Grillo
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Rakesh K Jain
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Thomas F DeLaney
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Dan G Duda
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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23
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Ding X, Dionisi F, Tang S, Ingram M, Hung CY, Prionas E, Lichtenwalner P, Butterwick I, Zhai H, Yin L, Lin H, Kassaee A, Avery S. A comprehensive dosimetric study of pancreatic cancer treatment using three-dimensional conformal radiation therapy (3DCRT), intensity-modulated radiation therapy (IMRT), volumetric-modulated radiation therapy (VMAT), and passive-scattering and modulated-scanning proton therapy (PT). Med Dosim 2014; 39:139-45. [PMID: 24661778 DOI: 10.1016/j.meddos.2013.11.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/27/2013] [Accepted: 11/11/2013] [Indexed: 12/31/2022]
Abstract
With traditional photon therapy to treat large postoperative pancreatic target volume, it often leads to poor tolerance of the therapy delivered and may contribute to interrupted treatment course. This study was performed to evaluate the potential advantage of using passive-scattering (PS) and modulated-scanning (MS) proton therapy (PT) to reduce normal tissue exposure in postoperative pancreatic cancer treatment. A total of 11 patients with postoperative pancreatic cancer who had been previously treated with PS PT in University of Pennsylvania Roberts Proton Therapy Center from 2010 to 2013 were identified. The clinical target volume (CTV) includes the pancreatic tumor bed as well as the adjacent high-risk nodal areas. Internal (iCTV) was generated from 4-dimensional (4D) computed tomography (CT), taking into account target motion from breathing cycle. Three-field and 4-field 3D conformal radiation therapy (3DCRT), 5-field intensity-modulated radiation therapy, 2-arc volumetric-modulated radiation therapy, and 2-field PS and MS PT were created on the patients' average CT. All the plans delivered 50.4Gy to the planning target volume (PTV). Overall, 98% of PTV was covered by 95% of the prescription dose and 99% of iCTV received 98% prescription dose. The results show that all the proton plans offer significant lower doses to the left kidney (mean and V18Gy), stomach (mean and V20Gy), and cord (maximum dose) compared with all the photon plans, except 3-field 3DCRT in cord maximum dose. In addition, MS PT also provides lower doses to the right kidney (mean and V18Gy), liver (mean dose), total bowel (V20Gy and mean dose), and small bowel (V15Gy absolute volume ratio) compared with all the photon plans and PS PT. The dosimetric advantage of PT points to the possibility of treating tumor bed and comprehensive nodal areas while providing a more tolerable treatment course that could be used for dose escalation and combining with radiosensitizing chemotherapy.
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Affiliation(s)
- Xuanfeng Ding
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Francesco Dionisi
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Shikui Tang
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Mark Ingram
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Chun-Yu Hung
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Evangelos Prionas
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Phil Lichtenwalner
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Ian Butterwick
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Huifang Zhai
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Lingshu Yin
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Haibo Lin
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Alireza Kassaee
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA
| | - Stephen Avery
- Perelman School of Medicine, Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
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24
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Wo JY, Mamon HJ, Ferrone CR, Ryan DP, Blaszkowsky LS, Kwak EL, Tseng YD, Napolitano BN, Ancukiewicz M, Swanson RS, Lillemoe KD, Fernandez-del Castillo C, Hong TS. Phase I study of neoadjuvant accelerated short course radiation therapy with photons and capecitabine for resectable pancreatic cancer. Radiother Oncol 2014; 110:160-4. [PMID: 24231241 DOI: 10.1016/j.radonc.2013.10.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 09/30/2013] [Accepted: 10/16/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE In this phase I study, we sought to determine the feasibility and tolerability of neoadjuvant short course radiotherapy (SC-CRT) delivered with photon RT with concurrent capecitabine for resectable pancreatic adenocarcinoma. MATERIALS AND METHODS Ten patients with localized, resectable pancreatic adenocarcinoma were enrolled from December 2009 to August 2011. In dose level I, patients received 3 Gy × 10. In dose level 2, patients received 5 Gy × 5 (every other day). In dose level 3, patients received 5 Gy × 5 (consecutive days). Capecitabine was given during weeks 1 and 2. Surgery was performed 1-3 weeks after completion of chemotherapy. RESULTS With an intended accrual of 12 patients, the study was closed early due to unexpected intraoperative complications. Compared to the companion phase I proton study, patients treated with photons had increased intraoperative RT fibrosis reported by surgeons (27% vs. 63%). Among those undergoing a Whipple resection, increased RT fibrosis translated to an increased mean OR time of 69 min. Dosimetric comparison revealed significantly increased low dose exposure to organs at risk for patients treated with photon RT. CONCLUSIONS This phase I experience evaluating the tolerability of neoadjuvant SC-CRT with photon RT closed early due to unexpected intraoperative complications.
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Affiliation(s)
- Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, United States.
| | - Harvey J Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, United States
| | - Cristina R Ferrone
- Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - David P Ryan
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Lawrence S Blaszkowsky
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Eunice L Kwak
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | | | - Brian N Napolitano
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Marek Ancukiewicz
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Richard S Swanson
- Department of General Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, United States
| | - Keith D Lillemoe
- Department of General Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | | | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, United States
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25
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Lee RY, Nichols RC, Huh SN, Ho MW, Li Z, Zaiden R, Awad ZT, Ahmed B, Hoppe BS. Proton therapy may allow for comprehensive elective nodal coverage for patients receiving neoadjuvant radiotherapy for localized pancreatic head cancers. J Gastrointest Oncol 2013; 4:374-9. [PMID: 24294509 DOI: 10.3978/j.issn.2078-6891.2013.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 07/17/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Neoadjuvant radiotherapy has the potential to improve local disease control for patients with localized pancreatic cancers. Concern about an increased risk of surgical complications due to small bowel and gastric exposure, however, has limited enthusiasm for this approach. Dosimetric studies have demonstrated the potential for proton therapy to reduce intestinal exposure compared with X-ray-based therapy. We sought to determine if neoadjuvant proton therapy allowed for field expansions to cover high-risk nodal stations in addition to the primary tumor. METHODS Twelve consecutive patients with nonmetastatic cancers of the pancreatic head underwent proton-based planning for neoadjuvant radiotherapy. Gross tumor volume was contoured using diagnostic computed tomography (CT) scans with oral and intravenous contrast. Four-dimensional planning scans were utilized to define an internal clinical target volume (ICTV). Five-mm planning target volume (PTV) expansions on the ICTV were generated to establish an initial PTV (PTV1). A second PTV was created using the initial PTV but was expanded to include the high-risk nodal targets as defined by the RTOG contouring atlas (PTV2). Optimized proton plans were generated for both PTVs for each patient. All PTVs received a dose of 50.4 cobalt gray equivalent (CGE). Normal-tissue exposures to the small bowel space, stomach, right kidney, left kidney and liver were recorded. Point spinal cord dose was limited to 45 CGE. RESULTS Median PTV1 volume was 308.75 cm(3) (range, 133.33-495.61 cm(3)). Median PTV2 volume was 541.75 cm(3) (range, 399.44-691.14 cm(3)). In spite of the substantial enlargement of the PTV when high-risk lymph nodes were included in the treatment volume, normal-tissue exposures (stomach, bowel space, liver, and kidneys) were only minimally increased relative to the exposures seen when only the gross tumor target was treated. CONCLUSIONS Proton therapy appears to allow for field expansions to cover high-risk lymph nodes without significantly increasing critical normal-tissue exposure in the neoadjuvant setting.
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Affiliation(s)
- Richard Y Lee
- Radiation Medicine, Roswell Park Cancer Institute, University at Buffalo, NY, USA
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Dosimetric predictors of nausea and vomiting: an exploratory analysis of a prospective phase I/II trial with neoadjuvant accelerated short-course radiotherapy and capecitabine for resectable pancreatic cancer. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13566-013-0114-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Nichols RC, George TJ, Zaiden RA, Awad ZT, Asbun HJ, Huh S, Ho MW, Mendenhall NP, Morris CG, Hoppe BS. Proton therapy with concomitant capecitabine for pancreatic and ampullary cancers is associated with a low incidence of gastrointestinal toxicity. Acta Oncol 2013; 52:498-505. [PMID: 23477361 DOI: 10.3109/0284186x.2012.762997] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND To review treatment toxicity for patients with pancreatic and ampullary cancer treated with proton therapy at our institution. MATERIAL AND METHODS From March 2009 through April 2012, 22 patients were treated with proton therapy and concomitant capecitabine (1000 mg PO twice daily) for resected (n = 5); marginally resectable (n = 5); and unresectable/inoperable (n = 12) biopsy-proven pancreatic and ampullary adenocarcinoma. Two patients with unresectable disease were excluded from the analysis for reasons unrelated to treatment. Proton doses ranged from 50.40 cobalt gray equivalent (CGE) to 59.40 CGE. RESULTS Median follow-up for all patients was 11 (range 5-36) months. No patient demonstrated any grade 3 toxicity during treatment or during the follow-up period. Grade 2 gastrointestinal toxicities occurred in three patients, consisting of vomiting (n = 3); and diarrhea (n = 2). Median weight loss during treatment was 1.3 kg (1.75% of body weight). Chemotherapy was well-tolerated with a median 99% of the prescribed doses delivered. Percentage weight loss was reduced (p = 0.0390) and grade 2 gastrointestinal toxicity was eliminated (p = 0.0009) in patients treated with plans that avoided anterior and left lateral fields which were associated with reduced small bowel and gastric exposure. DISCUSSION Proton therapy may allow for significant sparing of the small bowel and stomach and is associated with a low rate of gastrointestinal toxicity. Although long-term follow-up will be needed to assess efficacy, we believe that the favorable toxicity profile associated with proton therapy may allow for radiotherapy dose escalation, chemotherapy intensification, and possibly increased acceptance of preoperative radiotherapy for patients with resectable or marginally resectable disease.
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Affiliation(s)
- R. Charles Nichols
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
| | - Thomas J. George
- Department of Hematology and Medical Oncology, University of Florida,
Gainesville and Jacksonville, Florida, USA
| | - Robert A. Zaiden
- Department of Hematology and Medical Oncology, University of Florida,
Gainesville and Jacksonville, Florida, USA
| | - Ziad T. Awad
- Department of Surgery, University of Florida,
Jacksonville, FL, USA
| | | | - Soon Huh
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
| | - Meng Wei Ho
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
| | | | | | - bradford S. Hoppe
- University of Florida Proton Therapy Institute,
Jacksonville, Florida, USA
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Goodman KA, Hajj C. Role of radiation therapy in the management of pancreatic cancer. J Surg Oncol 2012; 107:86-96. [PMID: 22532174 DOI: 10.1002/jso.23137] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 04/03/2012] [Indexed: 12/16/2022]
Abstract
Local failure remains a major issue for patients with both resectable and locally advanced pancreatic cancer. The role of radiation therapy in the management of this disease is less clear and represents an area of some controversy. The objective of this review is to present the rationale for radiation therapy in pancreatic cancer, as well as to discuss the potential limitations and caveats of the currently available studies.
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Affiliation(s)
- Karyn A Goodman
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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Protons offer reduced normal-tissue exposure for patients receiving postoperative radiotherapy for resected pancreatic head cancer. Int J Radiat Oncol Biol Phys 2012; 83:158-63. [PMID: 22245197 DOI: 10.1016/j.ijrobp.2011.05.045] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 05/17/2011] [Accepted: 05/20/2011] [Indexed: 02/06/2023]
Abstract
PURPOSE To determine the potential role for adjuvant proton-based radiotherapy (PT) for resected pancreatic head cancer. METHODS AND MATERIALS Between June 2008 and November 2008, 8 consecutive patients with resected pancreatic head cancers underwent optimized intensity-modulated radiotherapy (IMRT) treatment planning. IMRT plans used between 10 and 18 fields and delivered 45 Gy to the initial planning target volume (PTV) and a 5.4 Gy boost to a reduced PTV. PTVs were defined according to the Radiation Therapy Oncology Group 9704 radiotherapy guidelines. Ninety-five percent of PTVs received 100% of the target dose and 100% of the PTVs received 95% of the target dose. Normal tissue constraints were as follows: right kidney V18 Gy to <70%; left kidney V18 Gy to <30%; small bowel/stomach V20 Gy to <50%, V45 Gy to <15%, V50 Gy to <10%, and V54 Gy to <5%; liver V30 Gy to <60%; and spinal cord maximum to 46 Gy. Optimized two- to three-field three-dimensional conformal proton plans were retrospectively generated on the same patients. The team generating the proton plans was blinded to the dose distributions achieved by the IMRT plans. The IMRT and proton plans were then compared. A Wilcoxon paired t-test was performed to compare various dosimetric points between the two plans for each patient. RESULTS All proton plans met all normal tissue constraints and were isoeffective with the corresponding IMRT plans in terms of PTV coverage. The proton plans offered significantly reduced normal-tissue exposure over the IMRT plans with respect to the following: median small bowel V20 Gy, 15.4% with protons versus 47.0% with IMRT (p = 0.0156); median gastric V20 Gy, 2.3% with protons versus 20.0% with IMRT (p = 0.0313); and median right kidney V18 Gy, 27.3% with protons versus 50.5% with IMRT (p = 0.0156). CONCLUSIONS By reducing small bowel and stomach exposure, protons have the potential to reduce the acute and late toxicities of postoperative chemoradiation in this setting.
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Shinohara ET, Kassaee A, Mitra N, Vapiwala N, Plastaras JP, Drebin J, Wan F, Metz JM. Feasibility of electromagnetic transponder use to monitor inter- and intrafractional motion in locally advanced pancreatic cancer patients. Int J Radiat Oncol Biol Phys 2011; 83:566-73. [PMID: 22099029 DOI: 10.1016/j.ijrobp.2011.07.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 06/12/2011] [Accepted: 07/11/2011] [Indexed: 01/08/2023]
Abstract
PURPOSE The primary objective of this study was to determine the feasibility of electromagnetic transponder implantation in patients with locally advanced unresectable pancreatic cancer. Secondarily, the use of transponders to monitor inter- and intrafractional motion, and the efficacy of breath holding for limiting target motion, were examined. METHODS AND MATERIALS During routine screening laparoscopy, 5 patients without metastatic disease were implanted with transponders peri-tumorally. The Calypso System's localization and tracking modes were used to monitor inter- and intrafractional motion, respectively. Intrafractional motion, with and without breath holding, was also examined using Calypso tracking mode. RESULTS Transponder implantation was well tolerated in all patients, with minimal migration, aside from 1 patient who expulsed a single transponder. Interfractional motion based on mean shifts from setup using tattoos/orthogonal imaging to transponder based localization from 164 treatments was significant in all dimensions. Mean shift (in millimeters), followed by the standard deviation and p value, were as follows: X-axis: 4.5 mm (1.0, p = 0.01); Y axis: 6.4 mm (1.9, p = 0.03); and Z-axis 3.9 mm (0.6, p = 0.002). Mean intrafractional motion was also found to be significant in all directions: superior, 7.2 mm (0.9, p = 0.01); inferior, 11.9 mm (0.9, p < 0.01); anterior: 4.9 mm (0.5, p = 0.01); posterior, 2.9 mm (0.5, p = 0.02); left, 2.2 mm (0.4, p = 0.02); and right, 3.1 mm (0.6, p = 0.04). Breath holding during treatment significantly decreased tumor motion in all directions. CONCLUSIONS Electromagnetic transponder implantation appears to be safe and effective for monitoring inter- and intrafractional motion. Based on these results a larger clinical trial is underway.
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Affiliation(s)
- Eric T Shinohara
- Department of Radiation Oncology, The Vanderbilt Clinic, Nashville, TN 37232e5671, USA.
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Chua TC, Saxena A. Preoperative chemoradiation followed by surgical resection for resectable pancreatic cancer: a review of current results. Surg Oncol 2011; 20:e161-8. [PMID: 21704510 DOI: 10.1016/j.suronc.2011.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 05/19/2011] [Accepted: 05/19/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND There has been an interest in the interdisciplinary and multimodality approach that combines chemotherapy and radiation therapy as a preoperative treatment for patients with resectable pancreatic cancer. METHODS Literature search of databases (Medline and PubMed) to identify published studies of preoperative chemoradiation for resectable pancreatic cancer (potentially resectable and borderline resectable) was undertaken. Response to treatment and survival outcomes was examined as endpoints of this review. RESULTS Seventeen studies; eight phase II studies, and nine observational studies, comprising of 977 patients were reviewed. Gemcitabine-based chemotherapy with radiotherapy was the most common preoperative regimen. Following preoperative treatment, pancreatic surgical resection was performed in 35-100% (median=61%) of patients after a range of 6-32 weeks (median=7 weeks). Rate of pathological response was complete in 5-15% of patients, partial in 33-60% and minimal in 38-42%. The median overall survival ranged from 12 months to 40 months (median=25 months) with a 5-year overall survival rate ranging between 8% and 36% (median=28%). Patients who underwent chemoradiation but did not undergo surgery survived a median period of 7-11 months (median=9 months). CONCLUSION Preoperative gemcitabine-based chemoradiation followed by restaging and surgical evaluation for pancreatic resection may identify a sub-population of patients with resectable disease who would benefit the most from surgery. Investigation of this schema of preoperative therapy in a randomized setting of resectable pancreatic cancer is warranted.
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Affiliation(s)
- Terence C Chua
- Hepatobiliary and Surgical Oncology Unit, University of New South Wales, Department of Surgery, St George Hospital, Kogarah, NSW 2217, Sydney, Australia.
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Hong TS, Ryan DP, Blaszkowsky LS, Mamon HJ, Kwak EL, Mino-Kenudson M, Adams J, Yeap B, Winrich B, DeLaney TF, Fernandez-Del Castillo C. Phase I study of preoperative short-course chemoradiation with proton beam therapy and capecitabine for resectable pancreatic ductal adenocarcinoma of the head. Int J Radiat Oncol Biol Phys 2010; 79:151-7. [PMID: 20421151 DOI: 10.1016/j.ijrobp.2009.10.061] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Revised: 10/17/2009] [Accepted: 10/24/2009] [Indexed: 01/12/2023]
Abstract
PURPOSE To evaluate the safety of 1 week of chemoradiation with proton beam therapy and capecitabine followed by early surgery. METHODS AND MATERIALS Fifteen patients with localized resectable, pancreatic adenocarcinoma of the head were enrolled from May 2006 to September 2008. Patients received radiation with proton beam. In dose level 1, patients received 3 GyE × 10 (Week 1, Monday-Friday; Week 2, Monday-Friday). Patients in Dose Levels 2 to 4 received 5 GyE × 5 in progressively shortened schedules: level 2 (Week 1, Monday, Wednesday, and Friday; Week 2, Tuesday and Thursday), Level 3 (Week 1, Monday, Tuesday, Thursday, and Friday; Week 2, Monday), Level 4 (Week 1, Monday through Friday). Capecitabine was given as 825 mg/m(2) b.i.d. Weeks 1 and 2 Monday through Friday for a total of 10 days in all dose levels. Surgery was performed 4 to 6 weeks after completion of chemotherapy for Dose Levels 1 to 3 and then after 1 to 3 weeks for Dose Level 4. RESULTS Three patients were treated at Dose Levels 1 to 3 and 6 patients at Dose Level 4, which was selected as the MTD. No dose limiting toxicities were observed. Grade 3 toxicity was noted in 4 patients (pain in 1; stent obstruction or infection in 3). Eleven patients underwent resection. Reasons for no resection were metastatic disease (3 patients) and unresectable tumor (1 patient). Mean postsurgical length of stay was 6 days (range, 5-10 days). No unexpected 30-day postoperative complications, including leak or obstruction, were found. CONCLUSIONS Preoperative chemoradiation with 1 week of proton beam therapy and capecitabine followed by early surgery is feasible. A Phase II study is underway.
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Affiliation(s)
- Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Bouchard M, Amos RA, Briere TM, Beddar S, Crane CH. Dose escalation with proton or photon radiation treatment for pancreatic cancer. Radiother Oncol 2009; 92:238-43. [PMID: 19454367 DOI: 10.1016/j.radonc.2009.04.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 04/16/2009] [Accepted: 04/18/2009] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose was to determine the optimal radiation therapy modality (three-dimensional conformal photon-radiation therapy [3DCRT], intensity-modulated photon-radiation therapy [IMRT], or passive-scattering proton therapy [PT]) for safe dose escalation (72Gy) in pancreatic tumors in different positions relative to organs at risk (OAR) anatomy. METHODS AND MATERIALS A 3-cm pancreatic tumor was virtually translated every 5mm over 5cm laterally. We generated two plans for each of the three techniques (3DCRT, IMRT, and PT), one that adhered to target coverage objectives and another to meet OAR sparing constraints with best coverage. We evaluated distances between gross tumor volumes and isodoses and compared dose-volume histograms. RESULTS IMRT was more conformal in higher gradient dose regions circumferentially, but tumor positions with anteriorly located small bowel benefited more from PT. 3DCRT plans resulted in inadequate target coverage. The V(15Gy) (mean+/-SD) were as follows for the IMRT and PT plans, respectively: stomach, 48%+/-4% vs 5%+/-3% (p<0.0001); and small bowel, 61%+/-8% vs 9%+/-4% (p<0.0001). CONCLUSIONS Our study showed that the optimal radiation therapy modality for safe dose escalation depends on pancreatic tumor position in relation to OAR anatomy.
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Affiliation(s)
- Myriam Bouchard
- Department of Radiation Physics, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Meyer JJ, Willett CG, Czito BG. Is there a role for advanced radiation therapy technologies in the treatment of pancreatic adenocarcinoma? Future Oncol 2008; 4:241-55. [DOI: 10.2217/14796694.4.2.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pancreatic cancer remains a highly challenging problem in oncology. Oncologists continue to search for therapies that are more effective than those currently available to improve on the existing poor treatment results. Persistence of both systemic and local disease causes high rates of morbidity and mortality for patients. Radiation continues to play a role in the treatment of pancreatic cancer, in both the adjuvant and locally advanced settings. Efforts to improve on the results of radiotherapy have led to the use of new and improved technologies. This review discusses a variety of these technological improvements and their current and potential future roles in the clinic.
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Affiliation(s)
- Jeffrey John Meyer
- Duke University Medical Center, Department of Radiation Oncology, DUMC Box 3085, Durham, NC 27710, USA
| | | | - Brian Gary Czito
- Duke University Medical Center, Department of Radiation Oncology, DUMC Box 3085, Durham, NC 27710, USA
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