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Mukherjee S, Qi C, Shaw R, Jones CM, Bridgewater JA, Radhakrishna G, Patel N, Holmes J, Virdee PS, Tranter B, Parsons P, Falk S, Wasan HS, Ajithkumar TV, Holyoake D, Roy R, Scott-Brown M, Hurt CN, O'Neill E, Sebag-Montefiore D, Maughan TS, Hawkins MA, Corrie P. Standard or high dose chemoradiotherapy, with or without the protease inhibitor nelfinavir, in patients with locally advanced pancreatic cancer: The phase 1/randomised phase 2 SCALOP-2 trial. Eur J Cancer 2024; 209:114236. [PMID: 39059185 DOI: 10.1016/j.ejca.2024.114236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/08/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND The multi-centre two-stage SCALOP-2 trial (ISRCTN50083238) assessed whether dose escalation of consolidative chemoradiotherapy (CRT) or concurrent sensitization using the protease inhibitor nelfinavir improve outcomes in locally advanced pancreatic cancer (LAPC) following four cycles of gemcitabine/nab-paclitaxel. METHODS In stage 1, the maximum tolerated dose (MTD) of nelfinavir concurrent with standard-dose CRT (50.4 Gy in 28 fractions) was identified from a cohort of 27 patients. In stage 2, 159 patients were enrolled in an open-label randomized controlled comparison of standard versus high dose (60 Gy in 30 fractions) CRT, with or without nelfinavir at MTD. Primary outcomes following dose escalation and nelfinavir use were respectively overall survival (OS) and progression free survival (PFS). Secondary endpoints included health-related quality of life (HRQoL). RESULTS High dose CRT did not improve OS (16.9 (60 % confidence interval, CI 16.2-17.7) vs. 15.6 (60 %CI 14.3-18.2) months; adjusted hazard ratio, HR 1.13 (60 %CI 0.91-1.40; p = 0.68)). Similarly, median PFS was not improved by nelfinavir (10.0 (60 %CI 9.9-10.2) vs. 11.1 (60 %CI 10.3-12.8) months; adjusted HR 1.71 (60 %CI 1.38-2.12; p = 0.98)). Local progression at 12 months was numerically lower with high-dose CRT than with standard dose CRT (n = 11/46 (23.9 %) vs. n = 15/45 (33.3 %)). Neither nelfinavir nor radiotherapy dose escalation impacted on treatment compliance or grade 3/4 adverse event rate. There were no sustained differences in HRQoL scores between treatment groups over 28 weeks post-treatment. CONCLUSIONS Dose-escalated CRT may improve local tumour control and is well tolerated when used as consolidative treatment in LAPC but does not impact OS. Nelfinavir use does not improve PFS.
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Affiliation(s)
- Somnath Mukherjee
- Oxford Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Cathy Qi
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Rachel Shaw
- Oncology Clinical Trials Office (OCTO), Department of Oncology, University of Oxford, Oxford, UK
| | - Christopher M Jones
- Department of Oncology, University of Cambridge, Cambridge, UK; Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - John A Bridgewater
- UCL Cancer Institute, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ganesh Radhakrishna
- The Christie Hospital, The Christie Hospitals NHS Foundation Trust, Manchester, UK
| | - Neel Patel
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Pradeep S Virdee
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Bethan Tranter
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, UK
| | - Philip Parsons
- Velindre Cancer Centre, Velindre University NHS Trust, Cardiff, UK
| | - Stephen Falk
- Bristol Cancer Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Harpreet S Wasan
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Thankamma V Ajithkumar
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Daniel Holyoake
- Norfolk & Norwich University Hospital, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Rajarshi Roy
- Queen's Centre for Oncology, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Martin Scott-Brown
- Coventry Cancer Centre, University Hospital Coventry & Warwickshire, Coventry, UK
| | | | - Eric O'Neill
- Department of Oncology, University of Oxford, Oxford, UK
| | | | - Tim S Maughan
- Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
| | - Maria A Hawkins
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Pippa Corrie
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Wei H, Han W, Zhang X, Zhang M. Gastroscopic observation and dose-volume histogram parameter study on gastrointestinal mucous injury for pancreatic cancer treated with TOMO. Medicine (Baltimore) 2024; 103:e38469. [PMID: 38905414 PMCID: PMC11191859 DOI: 10.1097/md.0000000000038469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024] Open
Abstract
To explore the relationships between gastrointestinal radiation injuries of pancreatic cancer patients treated with TOMO and dose-volume histogram parameters prospectively. Seventy patients with pancreatic cancer who underwent TOMO were enrolled in this prospective study from February 2015 to May 2020. The clinical and dose-volume histogram parameters of the patients were collected. The optimal dose parameters for gastrointestinal radiation ulcers were confirmed based on the receiver operating characteristic curve (ROC) and the area below the ROC curve. Acute gastrointestinal tract toxic and side effect and injury grading correlation analyzed by Kruskal-Wallis rank sum test. Gastrointestinal injury often occurs during radiotherapy for pancreatic cancer, as observed using gastroscopy. The main adverse reactions were radioactive gastrointestinal inflammation (58.5%), radioactive gastrointestinal ulcers (41.4%), active bleeding (10%), newly-developed gastric retention (8.6%), and gastric varices (5.7%). As for the stomach, Dmean and V10 were related to radiation ulcer injury. ROC curve indicated that for stomach a Dmean of 13.39 Gy (area under ROC curves = 0.74, P = .048) and a V10 of 72.21% (area = 0.74, P = .048) was the tolerated dose for the injury of stomach radiation ulcer. As for duodenum, aV20 and aV25 are related to radiation ulcer injury. ROC curve indicated that aV20 of 22.82 cm3 (area = 0.68, P = .025) and aV25 of 32.04 cm3 (area = 0.66, P < .047) was the tolerated dose for the injury of duodenum radiation ulcer. The acute gastrointestinal tract toxic and side effects have no significant correlation with injury grading under gastroscope. Dmean > 13.39 Gy and V10 > 72.21% were the key dosimetric indices for predicting radiation-induced gastric ulcer, and aV20 > 22.82 cm3 and aV25 > 32.04 cm3 were for duodenal. Gastrointestinal reactions cannot be used as an overall basis for the diagnosis of gastrointestinal injury, and gastroscopy is recommended as a review item after radiotherapy.
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Affiliation(s)
- Hualin Wei
- Department of Oncology, Hebei General Hospital, Shijiazhuang 050051, Hebei, PR China
| | - Wei Han
- Department of Oncology, Hebei General Hospital, Shijiazhuang 050051, Hebei, PR China
| | - Xianbo Zhang
- Department of Oncology, Hebei General Hospital, Shijiazhuang 050051, Hebei, PR China
| | - Ming Zhang
- Department of Oncology, Hebei General Hospital, Shijiazhuang 050051, Hebei, PR China
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Eidex Z, Ding Y, Wang J, Abouei E, Qiu RLJ, Liu T, Wang T, Yang X. Deep learning in MRI-guided radiation therapy: A systematic review. J Appl Clin Med Phys 2024; 25:e14155. [PMID: 37712893 PMCID: PMC10860468 DOI: 10.1002/acm2.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/10/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023] Open
Abstract
Recent advances in MRI-guided radiation therapy (MRgRT) and deep learning techniques encourage fully adaptive radiation therapy (ART), real-time MRI monitoring, and the MRI-only treatment planning workflow. Given the rapid growth and emergence of new state-of-the-art methods in these fields, we systematically review 197 studies written on or before December 31, 2022, and categorize the studies into the areas of image segmentation, image synthesis, radiomics, and real time MRI. Building from the underlying deep learning methods, we discuss their clinical importance and current challenges in facilitating small tumor segmentation, accurate x-ray attenuation information from MRI, tumor characterization and prognosis, and tumor motion tracking. In particular, we highlight the recent trends in deep learning such as the emergence of multi-modal, visual transformer, and diffusion models.
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Affiliation(s)
- Zach Eidex
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
- School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
| | - Yifu Ding
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jing Wang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Elham Abouei
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Richard L. J. Qiu
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Tian Liu
- Department of Radiation OncologyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Tonghe Wang
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
- School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
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Meindl M, Bläske A, Steiger K, Lindner S, Lindheimer F, Lauber K, Brix N, von Ungern-Sternberg B, Oos R, Palumbo G, Böning G, Schüle S, Majewski M, Port M, Ziegler S, Bartenstein P. Proliferation and apoptosis after whole-body irradiation: longitudinal PET study in a mouse model. Eur J Nucl Med Mol Imaging 2024; 51:395-404. [PMID: 37796306 PMCID: PMC10774227 DOI: 10.1007/s00259-023-06430-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023]
Abstract
PURPOSE A reliable method for regional in vivo imaging of radiation-induced cellular damage would be of great importance for the detection of therapy-induced injury to healthy tissue and the choice of adequate treatment of radiation emergency patients in both civilian and military events. This study aimed to investigate in a mouse model if positron emission tomography (PET) imaging with proliferation and apoptosis markers is potentially suitable for this purpose. METHODS Four groups, including twenty mice (wild-type C57BL/6) each, were whole-body irradiated with 0 Gy, 0.5 Gy, 1 Gy, and 3 Gy and examined by PET over a six-month period at defined time points. 3'-[18F]fluoro-3'-deoxythymidine ([18F]FLT) and 2-(5-[18F]fluoropentyl)-2-methyl malonic acid ([18F]ML-10) were used to visualise proliferation and apoptosis. Regional standard uptake values were compared with respect to irradiation dose over time. Histologic data and peripheral blood cell values were correlated with the PET results. RESULTS The hematopoietic bone marrow showed a significantly increased [18F]FLT signal at early time points after radiation exposure (day 3 and day 7). This correlated with blood parameters, especially leukocytes, and histological data. A significantly increased [18F]FLT signal also occurred in the gastrointestinal tract and thymus at early time points. An increased [18F]ML-10 signal related to irradiation doses was observed in the bone marrow on day 8, but there was a high variability of standard uptake values and no correlation with histological data. CONCLUSION [18F]FLT showed potential to visualise the extent, regional distribution and recovery from radiation-induced cellular damage in the bone marrow, gastrointestinal tract and thymus. The potential of [18F]FLT imaging to assess the extent of bone marrow affected by irradiation might be especially useful to predict the subsequent severity of hematopoietic impairment and to adapt the therapy of the bone marrow reserve. [18F]ML-10 PET proved to be not sensitive enough for the reliable detection of radiation induced apoptosis.
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Affiliation(s)
- Maria Meindl
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany.
| | - Alexandra Bläske
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Katja Steiger
- Comparative Experimental Pathology, Institute of Pathology, TU Munich, Munich, Germany
| | - Simon Lindner
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Felix Lindheimer
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Kirsten Lauber
- Department of Radiotherapy and Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nikko Brix
- Department of Radiotherapy and Radiation Oncology, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Rosel Oos
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Giovanna Palumbo
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Guido Böning
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Simone Schüle
- Department of Radiology, Bundeswehr Hospital, Ulm, Germany
| | | | - Matthias Port
- Bundeswehr Institute of Radiobiology, Munich, Germany
| | - Sibylle Ziegler
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, LMU University Hospital, LMU Munich, Munich, Germany
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Liu X, Hou X, Hu K, Zhang F, Wang W, Ren K. Risk Factors for Nodal Failure in Patients with FIGO IIIC Cervical Cancer Receiving Definitive Image-Guided Radiotherapy. Curr Oncol 2023; 30:10385-10395. [PMID: 38132390 PMCID: PMC10742234 DOI: 10.3390/curroncol30120756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Nodal failure is a major failure pattern for patients with FIGO IIIC cervical cancer, which is further associated with worse survival. This study was designed to investigate risk factors for nodal failure in FIGO IIIC cervical cancer patients. METHODS The characteristics of positive lymph nodes (LNs) and relevant clinical factors of 162 FIGO IIIC cervical cancer patients were collected. The chi-square test and logistic regression model were used to identify risk factors for nodal failure. RESULTS In total, 368 positive LNs were identified, including 307 pelvic LNs and 61 para-aortic LNs. The nodal failure rates for all LNs, pelvic LNs, and para-aortic LNs were 9.2%, 7.8%, and 16.4%, respectively. After 20 fractions of RT, a nodal short diameter (D20F) ≥ 0.95 cm and a ratio of nodal shrinkage (ΔV20F) < 0.435 resulted; <4 cycles of chemotherapy indicated higher nodal failure rates for all LNs. For pelvic LNs, ΔV20F < 0.435 and <4 cycles of chemotherapy were associated with a higher incidence of nodal failure. For para-aortic LNs, ΔV20F < 0.435 was the only risk factor for nodal failure. CONCLUSIONS Para-aortic LNs were more likely to experience nodal failure than pelvic LNs. Nodal shrinkage during radiotherapy and cycles of chemotherapy were associated with nodal failure in patients with FIGO IIIC cervical cancer.
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Affiliation(s)
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China; (X.L.); (F.Z.); (W.W.); (K.R.)
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China; (X.L.); (F.Z.); (W.W.); (K.R.)
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Kraja F, Kauweloa K, Ganju RG, Hoover AC. Impact of bowel space contouring variability on radiation dose and volume assessments in treatment planning for gynaecologic cancers. J Med Radiat Sci 2023; 70:417-423. [PMID: 37394743 PMCID: PMC10715335 DOI: 10.1002/jmrs.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/20/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Correlations between radiation dose/volume measures and small bowel (SB) toxicity are inconsistent in the medical literature. We assessed the impact of inter-provider variation in bowel bag contouring technique on estimates of radiation dose received by the SB during pelvic radiotherapy. METHODS Ten radiation oncologists contoured rectum, bladder and bowel bags on treatment planning computed tomography (CT) scans of two patients receiving adjuvant radiation for endometrial cancer. A radiation plan was generated for each patient and used to determine the radiation dose/volume for each organ. Kappa statistics were applied to assess the inter-provider contouring agreement, and Levene test evaluated the homogeneity of variance for radiation dose/volume metrics, including the V45Gy (cm3 ). RESULTS The bowel bag showed greater variation in radiation dose/volume estimates compared to the bladder and rectum. The V45Gy ranged from 163 to 384 cm3 for data set A and 109 to 409 cm3 for dataset B. Kappa values were 0.82/0.83, 0.92/0.92 and 0.94/0.86 for the bowel bag, rectum, and bladder on data sets A/B, demonstrating lower inter-provider agreement for bowel bag compared with bladder and rectum. CONCLUSION Inter-provider contouring variability is more significant for the bowel bag than the rectum and bladder, with an associated greater variability in dose and volume estimates during radiation planning.
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Affiliation(s)
- Fatjona Kraja
- Department of OncologyUniversity Hospital Centre Mother TeresaTiranaAlbania
| | - Kevin Kauweloa
- Department of Radiation OncologyQueen's Medical CentreHonoluluHawaiiUSA
| | | | - Andrew C. Hoover
- Department of Radiation OncologyUniversity of Kansas Cancer Centre, Kansas University Medical CentreKansas CityKansasUSA
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Kraja F, Kauweloa K, Ganju RG, Hoover AC. Impact of bowel space contouring variability on radiation dose and volume assessments in treatment planning for gynaecologic cancers. J Med Radiat Sci 2023. [DOI: doi.org/10.1002/jmrs.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/20/2023] [Indexed: 09/03/2023] Open
Abstract
AbstractIntroductionCorrelations between radiation dose/volume measures and small bowel (SB) toxicity are inconsistent in the medical literature. We assessed the impact of inter‐provider variation in bowel bag contouring technique on estimates of radiation dose received by the SB during pelvic radiotherapy.MethodsTen radiation oncologists contoured rectum, bladder and bowel bags on treatment planning computed tomography (CT) scans of two patients receiving adjuvant radiation for endometrial cancer. A radiation plan was generated for each patient and used to determine the radiation dose/volume for each organ. Kappa statistics were applied to assess the inter‐provider contouring agreement, and Levene test evaluated the homogeneity of variance for radiation dose/volume metrics, including the V45Gy (cm3).ResultsThe bowel bag showed greater variation in radiation dose/volume estimates compared to the bladder and rectum. The V45Gy ranged from 163 to 384 cm3 for data set A and 109 to 409 cm3 for dataset B. Kappa values were 0.82/0.83, 0.92/0.92 and 0.94/0.86 for the bowel bag, rectum, and bladder on data sets A/B, demonstrating lower inter‐provider agreement for bowel bag compared with bladder and rectum.ConclusionInter‐provider contouring variability is more significant for the bowel bag than the rectum and bladder, with an associated greater variability in dose and volume estimates during radiation planning.
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Affiliation(s)
- Fatjona Kraja
- Department of Oncology University Hospital Centre Mother Teresa Tirana Albania
| | - Kevin Kauweloa
- Department of Radiation Oncology Queen's Medical Centre Honolulu Hawaii USA
| | | | - Andrew C. Hoover
- Department of Radiation Oncology University of Kansas Cancer Centre, Kansas University Medical Centre Kansas City Kansas USA
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Broggi S, Passoni P, Tiberio P, Cicchetti A, Cattaneo GM, Longobardi B, Mori M, Reni M, Slim N, Del Vecchio A, Di Muzio NG, Fiorino C. Stomach and duodenum dose-volume constraints for locally advanced pancreatic cancer patients treated in 15 fractions in combination with chemotherapy. Front Oncol 2023; 12:983984. [PMID: 36761419 PMCID: PMC9902495 DOI: 10.3389/fonc.2022.983984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/19/2022] [Indexed: 01/25/2023] Open
Abstract
Purpose To assess dosimetry predictors of gastric and duodenal toxicities for locally advanced pancreatic cancer (LAPC) patients treated with chemo-radiotherapy in 15 fractions. Methods Data from 204 LAPC patients treated with induction+concurrent chemotherapy and radiotherapy (44.25 Gy in 15 fractions) were available. Forty-three patients received a simultaneous integrated boost of 48-58 Gy. Gastric/duodenal Common Terminology Criteria for Adverse Events v. 5 (CTCAEv5) Grade ≥2 toxicities were analyzed. Absolute/% duodenal and stomach dose-volume histograms (DVHs) of patients with/without toxicities were compared: the most predictive DVH points were identified, and their association with toxicity was tested in univariate and multivariate logistic regressions together with near-maximum dose (D0.03) and selected clinical variables. Results Toxicity occurred in 18 patients: 3 duodenal (ulcer and duodenitis) and 10 gastric (ulcer and stomatitis); 5/18 experienced both. At univariate analysis, V44cc (duodenum: p = 0.02, OR = 1.07; stomach: p = 0.01, OR = 1.12) and D0.03 (p = 0.07, OR = 1.19; p = 0.008, OR = 1.12) were found to be the most predictive parameters. Stomach/duodenum V44Gy and stomach D0.03 were confirmed at multivariate analysis and found to be sufficiently robust at internal, bootstrap-based validation; the results regarding duodenum D0.03 were less robust. No clinical variables or %DVH was significantly associated with toxicity. The best duodenum cutoff values were V44Gy < 9.1 cc (and D0.03 < 47.6 Gy); concerning the stomach, they were V44Gy < 2 cc and D0.03 < 45 Gy. The identified predictors showed a high negative predictive value (>94%). Conclusion In a large cohort treated with hypofractionated radiotherapy for LAPC, the risk of duodenal/gastric toxicities was associated with duodenum/stomach DVH. Constraining duodenum V44Gy < 9.1 cc, stomach V44Gy < 2 cc, and stomach D0.03 < 45 Gy should keep the toxicity rate at approximately or below 5%. The association with duodenum D0.03 was not sufficiently robust due to the limited number of events, although results suggest that a limit of 45-46 Gy should be safe.
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Affiliation(s)
- Sara Broggi
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Paolo Passoni
- Radiotherapy, San Raffaele Scientific Institute, Milano, Italy
| | - Paolo Tiberio
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Alessandro Cicchetti
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy,Unit of Data Science, Department of Epidemiology and Data Science, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | | | - Martina Mori
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy
| | - Michele Reni
- Oncology, San Raffaele Scientific Institute, Milano, Italy,Vita-Salute San Raffaele University, Milano, Italy
| | - Najla Slim
- Radiotherapy, San Raffaele Scientific Institute, Milano, Italy
| | | | - Nadia G. Di Muzio
- Radiotherapy, San Raffaele Scientific Institute, Milano, Italy,Vita-Salute San Raffaele University, Milano, Italy
| | - Claudio Fiorino
- Medical Physics, San Raffaele Scientific Institute, Milano, Italy,*Correspondence: Claudio Fiorino,
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Umezawa R, Nakagawa K, Mizuma M, Katsuta Y, Tanaka S, Kadoya N, Suzuki Y, Takeda K, Takahashi N, Yamamoto T, Unno M, Jingu K. Comparison of acute gastrointestinal toxicities between 3-dimensional conformal radiotherapy and intensity-modulated radiotherapy including prophylactic regions in chemoradiotherapy with S-1 for pancreatic cancer-importance of dose volume histogram parameters in the stomach as the predictive factors. JOURNAL OF RADIATION RESEARCH 2022; 63:856-865. [PMID: 35993332 PMCID: PMC9726699 DOI: 10.1093/jrr/rrac049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/28/2022] [Indexed: 06/15/2023]
Abstract
The purpose of this study was to compare acute gastrointestinal (GI) toxicities in patients who underwent 3-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) in chemoradiotherapy (CRT) with S-1 including prophylactic regions for pancreatic cancer. We also investigated the predictive factor of acute GI toxicities in dose volume histogram (DVH) parameters. Patients who received CRT with S-1 for pancreatic cancer between January 2014 and March 2021 were included. Radiotherapy (RT) with a total dose of 50-54 Gy was delivered. We examined the differences in the frequencies of acute GI toxicity of grade 2 or higher and DVH parameters of the stomach (ST) and duodenum (DU) between the 3DCRT group and the IMRT group. The RT-related predictive factors of acute GI toxicities were investigated by univariate and multivariate analyses. There were 25 patients in the 3DCRT group and 31 patients in the IMRT group. The frequencies of acute GI toxicity of G2 or higher were 36% in the 3DCRT group and 9.7% in the IMRT group (p = 0.035). ST V50 was the most predictive factor (p = 0.001), and the incidences of acute GI toxicity of G2 or higher in ST V50 ≥ 4.1 cc and < 4.1cc were 43.7% and 7.7%, respectively. ST V40 was also a significant predictive factor of acute GI toxicity (p = 0.002). IMRT could reduce acute GI toxicities in CRT with S-1 including prophylactic regions for pancreatic cancer. Acute GI toxicities may be affected by moderate to high doses to the ST.
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Affiliation(s)
- Rei Umezawa
- Corresponding author. Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1, Seiryou-machi, Aobaku, Sendai 980-8574, Japan. Tel: +81-22-717-7312; Fax: +81-22-717-7316; E-mail:
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshiyuki Katsuta
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shohei Tanaka
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuya Takeda
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Zeng C, Lu W, Reyngold M, Cuaron JJ, Li X, Cerviño L, Li T. Intrafractional accuracy and efficiency of a surface imaging system for deep inspiration breath hold during ablative gastrointestinal cancer treatment. J Appl Clin Med Phys 2022; 23:e13740. [PMID: 35906884 PMCID: PMC9680575 DOI: 10.1002/acm2.13740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 07/18/2022] [Accepted: 07/15/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Beam gating with deep inspiration breath hold (DIBH) usually depends on some external surrogate to infer internal target movement, and the exact internal movement is unknown. In this study, we tracked internal targets and characterized residual motion during DIBH treatment, guided by a surface imaging system, for gastrointestinal cancer. We also report statistics on treatment time. METHODS AND MATERIALS We included 14 gastrointestinal cancer patients treated with surface imaging-guided DIBH volumetrically modulated arc therapy, each with at least one radiopaque marker implanted near or within the target. They were treated in 25, 15, or 10 fractions. Thirteen patients received treatment for pancreatic cancer, and one underwent separate treatments for two liver metastases. The surface imaging system monitored a three-dimensional surface with ± 3 mm translation and ± 3° rotation threshold. During delivery, a kilovolt image was automatically taken every 20° or 40° gantry rotation, and the internal marker was identified from the image. The displacement and residual motion of the markers were calculated. To analyze the treatment efficiency, the treatment time of each fraction was obtained from the imaging and treatment timestamps in the record and verify system. RESULTS Although the external surface was monitored and limited to ± 3 mm and ± 3°, significant residual internal target movement was observed in some patients. The range of residual motion was 3-21 mm. The average displacement for this cohort was 0-3 mm. In 19% of the analyzed images, the magnitude of the instantaneous displacement was > 5 mm. The mean treatment time was 17 min with a standard deviation of 4 min. CONCLUSIONS Precaution is needed when applying surface image guidance for gastrointestinal cancer treatment. Using it as a solo DIBH technique is discouraged when the correlation between internal anatomy and patient surface is limited. Real-time radiographic verification is critical for safe treatments.
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Affiliation(s)
- Chuan Zeng
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Wei Lu
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Marsha Reyngold
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - John J. Cuaron
- Department of Radiation OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Xiang Li
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Laura Cerviño
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
| | - Tianfang Li
- Department of Medical PhysicsMemorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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11
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Moningi S, Lei X, Fang P, Taniguchi CM, Holliday EB, Koay EJ, Koong AC, Ludmir EB, Minsky BD, Das P, Giordano SH, Smith GL. Contemporary use and outcomes of radiation and chemotherapy for unresectable pancreatic cancer. Clin Transl Radiat Oncol 2022; 35:9-16. [PMID: 35510142 PMCID: PMC9058953 DOI: 10.1016/j.ctro.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 04/15/2022] [Accepted: 04/16/2022] [Indexed: 11/25/2022] Open
Abstract
This study examines 5,624 patients with unresectable pancreatic cancer. Across “real-world” US practice, overall use of radiation treatment (RT) has declined. Among those receiving RT, stereotactic body radiation treatment (SBRT) increased. Contemporary risks of gastrointestinal complications after SBRT have decreased.
Background We assessed radiation treatment (RT) use and complications for unresectable pancreatic cancer in the US, comparing conventionally fractionated (CFRT) and stereotactic body radiation treatment (SBRT) to inform real-world expected outcomes and practice. Material and Methods We analyzed 5,624 patients with non-metastatic, unresectable pancreatic cancer (2,522 older patients age > 65, diagnosed 2006–2013 in Medicare linked data; and 3,102 younger patients age < 65, diagnosed 2006–2016 in MarketScan data), comparing CFRT vs. SBRT vs. chemotherapy alone. Cochran-Armitage tested temporal trends. Fisher’s Exact Test and proportional hazards models compared gastrointestinal (GI) complications. Healthcare payments (Consumer Price Index adjusted to 2015) through 12 months were compared using generalized linear regression models with log link and gamma distribution. Results RT use declined from 55% to 45% of older patients (2006–2013) and 52% to 47% of younger patients (2006–2016) (Ptrend < 0.001 both). Among RT patients, SBRT use increased to 10% of older patients and 12% of younger patients in the most recent years (Ptrend = 0.04 and < 0.001 respectively). Addition of RT was associated with more frequent GI bleeds, strictures, and fistulas (Δ= +3% to 9% excess events, all P ≤ 0.05). Temporal patterns suggested decreasing complications over time (Ptrend = 0.05 and 0.05 for older and younger patients). Among younger patients, there was no difference in GI complications for SBRT vs. CFRT (P > 0.05, all comparisons). Among older patients, increased complications were seen for SBRT in 1–4 fractions vs. CFRT (P < 0.05), but not SBRT in 5 fractions (P = 0.72). Healthcare payments were greatest for SBRT when compared with CFRT or chemotherapy under US Medicare (P < 0.001) and employer-based insurance (P < 0.001). Conclusion Real-world treatment has shifted toward more selectivity for RT in unresectable pancreatic cancer. However, SBRT uptake and improving trends in complications profiles represent opportunities to optimize current use and benefit. Findings are applicable to inform future comparative and cost effectiveness models of RT for this disease.
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12
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Liermann J, Munter M, Naumann P, Abdollahi A, Krempien R, Debus J. Cetuximab, gemcitabine and radiotherapy in locally advanced pancreatic cancer: Long-term results of the randomized controlled phase II PARC trial. Clin Transl Radiat Oncol 2022; 34:15-22. [PMID: 35300246 PMCID: PMC8921472 DOI: 10.1016/j.ctro.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 01/18/2023] Open
Abstract
Final results of a randomized controlled phase II trial. OS and PFS data of neoadjuvant chemoradiation in pancreatic cancer. Combination of cetuximab, gemcitabine and IMRT is safe and feasible. Improvement of local tumor control and secondary resection rate by combined maintenance therapy with cetuximab and gemcitabine.
Purpose Addressing the epidermal growth factor receptor (EGFR)-pathway by the competitive receptor ligand cetuximab is a promising strategy in pancreatic cancer. In the prospective randomized controlled phase II PARC-study (PARC: Pancreatic cancer treatment with radiotherapy (RT) and cetuximab), we evaluated safety and efficacy of a trimodal treatment scheme consisting of cetuximab, gemcitabine and RT in locally advanced pancreatic cancer (LAPC). Methods Between January 2005 and April 2007, 68 patients with inoperable pancreatic ductal adenocarcinoma were randomized in either trimodal therapy followed by gemcitabine maintenance (Arm A) or in trimodal therapy followed by gemcitabine plus cetuximab maintenance (Arm B). Intensity-modulated RT (IMRT) was performed with a total dose of 45 Gy in 25 fractions and with a simultaneous integrated boost to the gross tumor (54 Gy). Within the trimodal therapy, gemcitabine and cetuximab were administered weekly. Maintenance therapy consisted of gemcitabine only or gemcitabine plus cetuximab. Toxicity, overall survival (OS), secondary resection rate, local control and progression free survival (PFS) were evaluated. Results With a median followup time of 13 months (range: 2 – 184 months), one patient is still alive and one patient is lost to follow-up. Nausea and gastrointestinal hemorrhage were the most important higher-graded (>°II) acute and late non-hematological toxicity (13% and 7%). Median OS was 13.1 months without significant difference between both treatment arms (Arm A: 11.9 months; Arm B: 14.2 months). Compared to historical data, cetuximab did not improve OS. One- and two-year local control rates were 76.6% and 68.9%. Local tumor control and secondary resection rate (Arm A: 4%; Arm B: 16%) were significantly improved in Arm B. Median PFS was 6.8 months with distant metastasis as main treatment failure. Conclusion Trimodal therapy consisting of IMRT, gemcitabine and cetuximab can be considered safe and feasible. Compared to historical data, cetuximab does not improve treatment efficacy in LAPC patients treated with chemoradiation.
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Affiliation(s)
- Jakob Liermann
- Heidelberg University Hospital, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- Corresponding author at: Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
| | - Marc Munter
- Klinikum Stuttgart, Department of Radiation Oncology, Kriegsbergstraße 60, 70174 Stuttgart, Germany
| | - Patrick Naumann
- Heidelberg University Hospital, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Amir Abdollahi
- Heidelberg University Hospital, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Robert Krempien
- Helios Clinic Berlin-Buch, Department of Radiation Oncology, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Juergen Debus
- Heidelberg University Hospital, Department of Radiation Oncology, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg
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13
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Parisi S, Ferini G, Cacciola A, Lillo S, Tamburella C, Santacaterina A, Bottari A, Brogna A, Ferrantelli G, Pontoriero A, Minutoli F, Pergolizzi S. A non-surgical COMBO-therapy approach for locally advanced unresectable pancreatic adenocarcinoma: preliminary results of a prospective study. LA RADIOLOGIA MEDICA 2022; 127:214-219. [PMID: 35034325 DOI: 10.1007/s11547-021-01441-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022]
Abstract
In this short report we present a series of thirteen patients with locally advanced, unresectable, pancreatic cancer treated with a COMBO-Therapy consisting of: STEP-1: induction chemotherapy; STEP-2: concomitant chemoradiotherapy; STEP-3: stereotactic body radiotherapy boost. After four weeks from the end of each step all patients had a re-staging and a surgical re-evaluation. All patients completed STEP-1 and STEP-2. STEP-3 has been successfully delivered to 8/13 patients with a median dose of 12 Gy (range 10-21 Gy) in 1-3 fractions. The median LC was 20 months (range 10-32) with a 2-year LC of 72.9%, and none of the patients developed G3 acute or late toxicities. The median OS was 21.5 months (range 12-34), and the 2-year OS was 53.9%; the median PFS was 17.5 months (range 10-27). Our non-surgical COMBO-Therapy has demonstrated a feasible profile with good tolerance. Further prospective protocols are needed to confirm our preliminary results.
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Affiliation(s)
- Silvana Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | | | - Alberto Cacciola
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Sara Lillo
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy.
| | - Consuelo Tamburella
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | | | - Antonio Bottari
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Anna Brogna
- Unit of Medical Physics, University Hospital Policlinico "G. Martino", Messina, Italy
| | - Giacomo Ferrantelli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Antonio Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Fabio Minutoli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Stefano Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
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14
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Lakomy DS, Wu J, Chapman BV, Yu ZH, Lee B, Klopp AH, Jhingran A, Eifel PJ, Lin LL. Use of specific duodenal dose constraints during treatment planning reduces toxicity after definitive para-aortic radiotherapy for cervical cancer. Pract Radiat Oncol 2021; 12:e207-e215. [PMID: 34958984 DOI: 10.1016/j.prro.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/21/2021] [Accepted: 12/03/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To validate the safety of paraaortic nodal (PAN) radiation therapy (RT) for patients with cervical cancer when the duodenal dose is limited to V55<15 cm3 and V60<2 cm3. METHODS AND MATERIALS Ninety-seven patients who were treated with RT for cervical cancer between 2010 and 2018, received at least 56 Gy to grossly involved PANs. Patients were treated with concurrent chemoradiation (n=88, 91%), with 93% (n=90) receiving intensity-modulated RT (IMRT) to the initial PAN field, and 98% (n=95) receiving IMRT to a sequential PAN boost. V55<15 cm3 and V60 <2 cm3 criteria were implemented in 2014. Normal tissues were contoured on CT simulation datasets; the duodenum was contoured from the gastric outlet to the duodenojejunal flexure. Sixty-six patients (68%) had a resimulation scan after approximately 20 fractions. Composite duodenal doses were calculated using the initial CT for 50 patients (52%) and the resimulation CT for 47 patients (48%) depending on anatomic changes throughout treatment. RESULTS The median duodenal V55 was 3.5 cm3 (interquartile range [IQR] 0.2-8.1 cm3) and the median V60 was 0.3 cm3 (IQR 0.0-1.8). Constraints were exceeded in 18 patients, 16 (89%) of whom had been treated before 2014. Treatment for the 2 patients treated after 2014 had been complicated by significant weight loss and reduced anterior-posterior diameter, which likely overestimated the true dose on the composite plan. Only 1 patient experienced grade 3 duodenal toxicity (stricture requiring endoscopic balloon dilation 3 months after treatment); however, the stricture was outside the high-dose boost volume and the patient had a history of gastritis. Six patients (6%) had a first recurrence within the PAN region. CONCLUSIONS Limiting duodenal dose to V55<15 cm3 and V60<2 cm3 for patients with cervical cancer and PAN involvement is feasible and minimizes duodenal toxicity while maintaining acceptable local control rates.
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Affiliation(s)
- David S Lakomy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Juliana Wu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA; The University of Texas School of Public Health, Houston, TX, USA
| | - Bhavana V Chapman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zhiqian Henry Yu
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Belinda Lee
- Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ann H Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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15
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Abstract
Dose constraints are essential for performing dosimetry, especially for intensity modulation and for radiotherapy under stereotaxic conditions. We present the update of the recommendations of the French society of oncological radiotherapy for the use of these doses in classical current practice but also for reirradiation.
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Affiliation(s)
- G Noël
- Département de radiothérapie-oncologie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France.
| | - D Antoni
- Département de radiothérapie-oncologie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
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16
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García García CJ, Acevedo Diaz AC, Kumari N, Govindaraju S, de la Cruz Bonilla M, San Lucas FA, Nguyen ND, Jiménez Sacarello I, Piwnica-Worms H, Maitra A, Taniguchi CM. HIF2 Regulates Intestinal Wnt5a Expression. Front Oncol 2021; 11:769385. [PMID: 34900719 PMCID: PMC8656274 DOI: 10.3389/fonc.2021.769385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/29/2021] [Indexed: 12/11/2022] Open
Abstract
Radiation therapy for abdominal tumors is challenging because the small intestine is exquisitely radiosensitive. Unfortunately, there are no FDA-approved therapies to prevent or mitigate GI radiotoxicity. The EGLN protein family are oxygen sensors that regulate cell survival and metabolism through the degradation of hypoxia-inducible factors (HIFs). Our group has previously shown that stabilization of HIF2 through genetic deletion or pharmacologic inhibition of the EGLNs mitigates and protects against GI radiotoxicity in mice by improving intestinal crypt stem cell survival. Here we aimed to elucidate the molecular mechanisms by which HIF2 confers GI radioprotection. We developed duodenal organoids from mice, transiently overexpressed non-degradable HIF2, and performed bulk RNA sequencing. Interestingly, HIF2 upregulated known radiation modulators and genes involved in GI homeostasis, including Wnt5a. Non-canonical Wnt5a signaling has been shown by other groups to improve intestinal crypt regeneration in response to injury. Here we show that HIF2 drives Wnt5a expression in multiple duodenal organoid models. Luciferase reporter assays performed in human cells showed that HIF2 directly activates the WNT5A promoter via a hypoxia response element. We then evaluated crypt regeneration using spheroid formation assays. Duodenal organoids that were pre-treated with recombinant Wnt5a had a higher cryptogenic capacity after irradiation, compared to vehicle-treated organoids. Conversely, we found that Wnt5a knockout decreased the cryptogenic potential of intestinal stem cells following irradiation. Treatment with recombinant Wnt5a prior to irradiation rescued the cryptogenic capacity of Wnt5a knockout organoids, indicating that Wnt5a is necessary and sufficient for duodenal radioprotection. Taken together, our results suggest that HIF2 radioprotects the GI tract by inducing Wnt5a expression.
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Affiliation(s)
- Carolina J. García García
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, United States
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- School of Medicine, University of Puerto Rico, Rio Piedras, PR, United States
| | | | - Neeraj Kumari
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Suman Govindaraju
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Marimar de la Cruz Bonilla
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, United States
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- School of Medicine, University of Puerto Rico, Rio Piedras, PR, United States
| | - F. Anthony San Lucas
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nicholas D. Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Helen Piwnica-Worms
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Anirban Maitra
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cullen M. Taniguchi
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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17
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Wang D, Wang W, Liu X, Ren K, Liang Y, Zhu Q, Zhang F, Hu K. A modified delineation method of para-aortic nodal clinical target volume in patients with locally advanced cervical cancer. Cancer Med 2021; 11:28-39. [PMID: 34783168 PMCID: PMC8704148 DOI: 10.1002/cam4.4418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/21/2021] [Accepted: 10/26/2021] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To validate the nodal center coverage (NCC) of the three mainstream delineation methods of para-aortic nodal clinical target volume (CTV) and propose a modified delineation method of para-aortic nodal CTV in prophylactic extended-field irradiation (EFI) of cervical cancer. METHODS A total of 106 patients with para-aortic lymph nodes (PALNs) identified on PET/CT were included at Peking Union Medical College Hospital between 2011 and 2020. PALNs were classified as left lateral para-aortic (LLPA), aorto-caval (AC), and right para-caval (RPC). Distances from the nodal center to the aorta and inferior vena cava (IVC) were measured. The NCC of the three mainstream delineation methods of para-aortic nodal CTV (CTV-K, CTV-S, and CTV-D) and a modified CTV (CTV-M) was calculated. Radiotherapy plans were created based on 4 CTVs for 10 selected patients who received prophylactic EFI. The chi-squared test and the Student's t-test were performed. RESULTS We identified 344 PALNs (216 LLPA, 101 AC, and 27 RPC) in 106 patients. Mean distance from the nodal center to the aorta was 9.6 mm in the LLPA and 7 mm in the AC and from the nodal center to the IVC was 5.6 mm in the AC and 5.6 mm in the RPC. CTV-D improved the NCC of 98% compared with 92% for CTV-K (p = 0.002) and 95% for CTV-S (p = 0.046). CTV-M provided the same satisfactory NCC as CTV-D (97% vs. 98%, p = 0.485). The V50Gy to the duodenum, the Dmean to the bilateral kidneys, and the V45Gy to the small bowel were significantly lower on the CTV-M-based plan than on the CTV-D-based plan (p = 0.001, 0.011, and 0.001, respectively). CONCLUSION CTV-D provided more satisfactory NCC than CTV-K and CTV-S. CTV-M provided the same satisfactory NCC as CTV-D and reduced the dose to the critical structures.
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Affiliation(s)
- Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kang Ren
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yongguang Liang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qizhen Zhu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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18
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Liu P, Gao XS, Wang Z, Li X, Xi C, Jia C, Xie M, Lyu F, Ding X. Investigate the Dosimetric and Potential Clinical Benefits Utilizing Stereotactic Body Radiation Therapy With Simultaneous Integrated Boost Technique for Locally Advanced Pancreatic Cancer: A Comparison Between Photon and Proton Beam Therapy. Front Oncol 2021; 11:747532. [PMID: 34631584 PMCID: PMC8493097 DOI: 10.3389/fonc.2021.747532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose To investigate the potential clinical benefits of using stereotactic body radiation therapy (SBRT) with simultaneous integrated boost (SIB) technique for locally advanced pancreatic cancer (LAPC) among different treatment modalities and planning strategies, including photon and proton. Method A total of 19 patients were retrospectively selected in this study: 13 cases with the tumor located in the head of the pancreas and 6 cases with the tumor in the body of the pancreas. SBRT-SIB plans were generated using volumetric modulated arc therapy (VMAT), two-field Intensity Modulated Proton Therapy (IMPT), and three-field IMPT. The IMPT used the robust optimization parameters of ± 3.5% range and 5-mm setup uncertainties. Root-mean-square deviation dose (RMSD) volume histograms were used to evaluate the target coverage robustness quantitatively. Dosimetric metrics based on the dose-volume histogram (DVH), homogeneity index (HI), and normal tissue complication probability (NTCP) were analyzed to evaluate the potential clinical benefits among different planning groups. Results With a similar CTV and SIB coverage, two-field IMPT provided a lower maximum dose for the stomach (median: 18.6GyE, p<0.05) and duodenum (median: 32.62GyE, p<0.05) when the target was located in the head of the pancreas compared to VMAT and three-field IMPT. The risks of gastric bleed (3.42%) and grade ≥ 3 GI toxicity (4.55%) were also decreased. However, for the target in the body of the pancreas, VMAT showed a lower maximum dose for the stomach (median 30.93GyE, p<0.05) and toxicity of gastric bleed (median: 8.67%, p<0.05) compared to two-field IMPT and three-field IMPT, while other maximum doses and NTCPs were similar. The RMSD volume histogram (RVH) analysis shows that three-field IMPT provided better robustness for targets but not for OARs. Instead, three-field IMPT increased the Dmean of organs such as the stomach, duodenum, and intestine. Conclusion The results indicated that the tumor locations could play a critical role in determining clinical benefits among different treatment modalities. Two-field IMPT could be a better option for LAPC patients whose tumors are located in the head of the pancreas. It provides lower severe toxicity for the stomach and duodenum. Nevertheless, VMAT is preferred for the body with better protection for the possibility of gastric bleed.
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Affiliation(s)
- Peilin Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Zishen Wang
- Department of Radiation Oncology, Hebei Yizhou Tumor Hospital, Zhuozhou, China
| | - Xiaomei Li
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Cao Xi
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Chenghao Jia
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Mu Xie
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Feng Lyu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Proton Beam Therapy Center, Royal Oak, MI, United States
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The Survival Benefit of Chemoradiotherapy following Induction Chemotherapy with Gemcitabine Plus Nab-Paclitaxel for Unresectable Locally Advanced Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13184733. [PMID: 34572960 PMCID: PMC8470784 DOI: 10.3390/cancers13184733] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/14/2021] [Accepted: 09/20/2021] [Indexed: 12/27/2022] Open
Abstract
Simple Summary An optimal therapeutic strategy for unresectable locally advanced pancreatic cancer (UR-LAPC) has not been established. The aim of this retrospective study was to evaluate the therapeutic efficacy, progression-free survival (PFS), and overall survival (OS) of patients with UR-LAPC who underwent gemcitabine plus nab-paclitaxel (GnP) as first-line chemotherapy followed by chemoradiotherapy (CRT) compared to chemotherapy alone (CTx) at our department in a Japanese cancer referral center between February 2015 and July 2018. CRT resulted in significantly better PFS and OS than CTx. In the multivariate analyses, CRT following induction chemotherapy was identified as an independent prognostic factor for OS. In summary, patients with UR-LAPC experienced favorable treatment outcomes after receiving GnP as the first-line chemotherapy, especially when receiving additional CRT after tailored courses of induction chemotherapy. Thus, this treatment strategy represents a promising treatment option for selected patients with UR-LAPC. Abstract An optimal therapeutic strategy for unresectable locally advanced pancreatic cancer (UR-LAPC) has not been established. This study investigated the therapeutic efficacy of chemoradiotherapy (CRT) following induction chemotherapy with gemcitabine plus nab-paclitaxel (GnP) (CRT group) compared with systemic chemotherapy alone (CTx group) in patients with UR-LAPC. This was a retrospective study of 63 consecutive patients with UR-LAPC treated at our department in a Japanese cancer referral center between February 2015 and July 2018. We excluded patients who underwent other regimens and those enrolled in another prospective study. The CRT group (n = 25) exhibited significantly better progression-free survival (PFS) and overall survival (OS) than the CTx group (n = 20, PFS 17.9 vs. 7.6 months, p = 0.044; OS 29.2 vs. 17.4 months, p < 0.001). In the multivariate analyses, CRT following induction chemotherapy was identified as an independent prognostic factor for OS. Seven (15.6%) patients underwent conversion surgery, all of whom were in the CRT group. The R0 resection rate was 85.7% (6/7). In summary, patients with UR-LAPC experienced favorable treatment outcomes after receiving GnP as the first-line chemotherapy, especially when receiving additional CRT. Thus, this treatment strategy represents a promising treatment option for selected patients with UR-LAPC.
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Wang D, Yang B, Wang W, Liu X, Liang Y, Sun S, Ma J, Zhou B, Hu K, Zhang F. Higher Dose to Organs at Risk: The Unintended Consequences of Intravenous Contrast Use in Computed Tomography Simulation for Cervical Cancer. Pract Radiat Oncol 2021; 11:534-543. [PMID: 34419624 DOI: 10.1016/j.prro.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE To compare the volumes of interest and doses to the organs at risk on contrast and noncontrast scans in patients with cervical cancer who underwent prophylactic extended-field radiation therapy (EFRT). METHODS AND MATERIALS We reviewed twenty cervical cancer patients treated with prophylactic EFRT at Peking Union Medical College Hospital between March 2021 and April 2021. Each patient underwent noncontrast and contrast scans during simulation. All structures were contoured, and radiation therapy plans were created based on both scans. Student t test and Pearson correlation coefficient test were performed. RESULTS Compared with the noncontrast scan, on the contrast scan, the mean volume of the inferior vena cava expanded by 44% (P ≤ .001), and the mean volume of the para-aortic nodal clinical target volume increased by 17% (P ≤ .001). For the second portion of the duodenum, the V30 (38.2% vs 43.8%, P = .038), V35 (27.6% vs 35.1%, P = .002), V40 (18.3% vs 26.3%, P = .014), V45 (11.2% vs 18.5%, P = .008), and V50 (4.2% vs 9.1%, P = .005) were significantly lower on the noncontrast scan than on the contrast scan. For the third portion of the duodenum, the V45 (78.4% vs 81.6%, P = .03) and V50 (59.7% vs 67%, P ≤ .001) were significantly lower on the noncontrast scan than on the contrast scan. For the right kidney, the V5, V10, V15, V20, and V25 on the contrast and noncontrast scans were 85.4% versus 79.8% (P = .013), 52.5% versus 45.6% (P = .021), 25.6% versus 20.1% (P = .003), 11.1% versus 7.5% (P = .001), and 3.8% versus 2.3% (P = .027), respectively. CONCLUSIONS Compared with the noncontrast scan, expansion of the inferior vena cava on the contrast scan can lead to excessive contouring and an overdose to the duodenum and right kidney in cervical cancer patients treated with prophylactic EFRT.
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Affiliation(s)
- Dunhuang Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yongguang Liang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shuai Sun
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiabin Ma
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bing Zhou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Jethwa KR, Sannapaneni S, Mullikin TC, Harmsen WS, Petersen MM, Antharam P, Laughlin B, Mahipal A, Halfdanarson TR, Merrell KW, Neben-Wittich M, Sio TT, Haddock MG, Hallemeier CL. Chemoradiotherapy for patients with locally advanced or unresectable extra-hepatic biliary cancer. J Gastrointest Oncol 2021; 11:1408-1420. [PMID: 33457010 DOI: 10.21037/jgo-20-245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Although surgical resection is the preferred curative-intent treatment option for patients with non-metastatic, extra-hepatic biliary cancer (EBC), radiotherapy (RT) or chemoradiotherapy (CRT) may be utilized in select cases when surgical resection is not feasible. The purpose of this study is to report the efficacy and adverse events (AEs) associated with CRT for patients with locally advanced and unresectable EBC. Methods This was a retrospective cohort study of patients with EBC, including extra-hepatic cholangiocarcinoma or gallbladder cancer, deemed inoperable who received RT between 1998 and 2018. The median RT dose was 50.4 Gy in 28 fractions and 94% received concurrent 5-fluorouracil. The Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS) from the start of RT. The cumulative incidence of local progression (LP), locoregional progression (LRP), and distant metastasis (DM) were reported with death as a competing risk. Cox proportional hazards regression models were used to assess for correlation between patient and treatment characteristics and outcomes. Results Forty-eight patients were included for analysis. The median OS was 12.0 months [95% confidence interval (CI): 2.3-73.2 months]. The 2-, 3-, and 5-year OS were 33% (95% CI: 22-50%), 20% (95% CI: 11-36%), and 7% (95% CI: 2-20%), respectively. The 2-year PFS, LP, LRP, and DM were 21% (95% CI: 12-36%), 27% (95% CI: 17-44%), 31% (95% CI: 20-48%), and 33% (95% CI: 22-50%), respectively. On univariate analysis, biologically effective dose (BED) >59.5 Gy10 was associated with improved OS [hazard ratio (HR): 0.40, 95% CI: 0.18-0.92, P=0.03] and PFS (HR: 0.37, 95% CI: 0.16-0.84, P=0.02) and primary tumor size (per 1 cm increase) was associated with worsened PFS (HR: 1.29, 95% CI: 1.02-1.63, P=0.04). BED >59.5 Gy10 remained associated with PFS on multivariate analysis (HR: 0.34, 95% CI: 0.15-0.78, P=0.01). Treatment-related grade 3+ acute and late gastrointestinal AEs occurred in 13% and 17% of patients, respectively. Conclusions RT is associated with 3- and 5-year survival in a subset of patients with unresectable EBC. Further exploration of the role of RT as part of a multi-modality curative treatment strategy is warranted.
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Affiliation(s)
- Krishan R Jethwa
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.,Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Shilpa Sannapaneni
- Department of Internal Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - William S Harmsen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Molly M Petersen
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Brady Laughlin
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Amit Mahipal
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Nakamura M, Nakao M, Mukumoto N, Ashida R, Hirashima H, Yoshimura M, Mizowaki T. Statistical shape model-based planning organ-at-risk volume: application to pancreatic cancer patients. Phys Med Biol 2021; 66:014001. [PMID: 33227722 DOI: 10.1088/1361-6560/abcd1b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
PURPOSE To introduce the concept of statistical shape model (SSM)-based planning organ-at-risk volume (sPRV) for pancreatic cancer patients. METHODS A total of 120 pancreatic cancer patients were enrolled in this study. After correcting inter-patient variations in the centroid position of the planning target volume (PTV), four different SSMs were constructed by registering a deformable template model to an individual model for the stomach and duodenum. The sPRV, which focused on the following different components of the inter-patient variations, was then created: Scenario A: shape, rotational angle, volume, and centroid position; Scenario B: shape, rotational angle, and volume; Scenario C: shape and rotational angle; and Scenario D: shape. The conventional PRV (cPRV) was created by adding an isotropic margin R (3-15 mm) to the mean shape model. The corresponding sPRV was created from the SSM until the volume difference between the cPRV and sPRV was less than 1%. Thereafter, we computed the overlapping volume between the PTV and cPRV (OLc) or sPRV (OLs) in each patient. OLs being larger than OLc implies that the local shape variations in the corresponding OAR close to the PTV were large. Therefore, OLs/OLc was calculated in each patient for each R-value, and the median value of OLs/OLc was regarded as a surrogate for plan quality for each R-value. RESULTS For R = 3 and 5 mm, OLs/OLc exceeded 1 for the stomach and duodenum in all scenarios, with a maximum OLs/OLc of 1.21. This indicates that smaller isotropic margins did not sufficiently account for the local shape changes close to the PTV. CONCLUSIONS Our results indicated that, in contrast to conventional PRV, SSM-based PRVs, which account for local shape changes, would result in better dose sparing for the stomach and duodenum in pancreatic cancer patients.
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Affiliation(s)
- Mitsuhiro Nakamura
- Division of Medical Physics, Department of Information Technology and Medical Engineering, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan. Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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23
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Zeng C, Li X, Lu W, Reyngold M, Gewanter RM, Cuaron JJ, Yorke E, Li T. Accuracy and efficiency of respiratory gating comparable to deep inspiration breath hold for pancreatic cancer treatment. J Appl Clin Med Phys 2020; 22:218-225. [PMID: 33378792 PMCID: PMC7856516 DOI: 10.1002/acm2.13137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/06/2020] [Accepted: 12/01/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Deep inspiration breath hold (DIBH) and respiratory gating (RG) are widely used to reduce movement of target and healthy organs caused by breathing during irradiation. We hypothesized that accuracy and efficiency comparable to DIBH can be achieved with RG for pancreas treatment. Methods and Materials Twenty consecutive patients with pancreatic cancer treated with DIBH (eight) or RG (twelve) volumetric modulated arc therapy during 2017–2019 were included in this study, with radiopaque markers implanted near or in the targets. Seventeen patients received 25 fractions, while the other three received 15 fractions. Only patients who could not tolerate DIBH received RG treatment. While both techniques relied on respiratory signals from external markers, internal target motions were monitored with kV X‐ray imaging during treatment. A 3‐mm external gating window was used for DIBH treatment; RG treatment was centered on end‐expiration with a duty cycle of 40%, corresponding to an external gating window of 2–3 mm. During dose delivery, kV images were automatically taken every 20◦ or 40◦ gantry rotation, from which internal markers were identified. The marker displacement from their initial positions and the residual motion amplitudes were calculated. For the analysis of treatment efficiency, the treatment time of every session was calculated from the motion management waveform files recorded at the treatment console. Results Within one fraction, the displacement was 0–5 mm for DIBH and 0–6 mm for RG. The average magnitude of displacement for each patient during the entire course of treatment ranged 0–3 mm for both techniques. No statistically significant difference in displacement or residual motion was observed between the two techniques. The average treatment time was 15 min for DIBH and 17 min for RG, with no statistical significance. Conclusions The accuracy and efficiency were comparable between RG and DIBH treatment for pancreas irradiation. RG is a feasible alternative strategy to DIBH.
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Affiliation(s)
- Chuan Zeng
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiang Li
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wei Lu
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard M Gewanter
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tianfang Li
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Regional Control and Chemoradiotherapy Dose Response for Clinically Involved Lymph Nodes in Patients with Locally Advanced Endometrial Cancers Who are Not Candidates for Upfront Surgical Staging Extrafascial Hysterectomy. Clin Oncol (R Coll Radiol) 2020; 33:e110-e117. [PMID: 32919862 DOI: 10.1016/j.clon.2020.08.009] [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: 05/03/2020] [Revised: 06/10/2020] [Accepted: 08/25/2020] [Indexed: 01/01/2023]
Abstract
AIMS There are limited data in endometrial cancer for nodal control and appropriate treatment volume for non-surgically resected nodes treated with chemoradiotherapy (CRT) for patients who are not candidates for upfront extrafascial hysterectomy. MATERIALS AND METHODS Patients (n = 105) with clinical stage ≥ II endometrial cancer who were not candidates for upfront extrafascial hysterectomy treated with preoperative CRT were retrospectively reviewed. CRT included pelvic nodes to the common iliac for node-negative disease and para-aortic nodes to the renal vessel for any node-positive disease. Involved nodes most commonly received a boost of 55 Gy in 25 fractions ± additional 4-6 Gy sequential boost for nodes >2 cm. RESULTS Of the included 95 patients, 55 patients were node positive, with a total of 300 positive nodes. At a median follow-up of 25 months (interquartile range 9-46), the 3-year regional control was 91%. The 3-year involved nodal control rate was 96%. Involved nodal control was significantly higher in type I histology, nodes <2 cm and by radiation dose (75% for <55 Gy, 98% for 55 Gy in 25 fractions and 89% for >55 Gy, P = 0.03). The 3-year para-aortic failure rate for node negative patients treated with pelvis-only CRT was significantly higher with positron emission tomography/computed tomography (PET/CT) versus computed tomography (CT)-based staging (0% versus 20%). CONCLUSION This is the largest study examining regional control rates of involved lymph nodes with CRT for patients who were not candidates for upfront extrafascial hysterectomy. Nodal failure was low following CRT and dose ≥55 Gy in 25 fractions seems to be adequate for involved nodes.
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25
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The use of intraoperative radiation therapy in the management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Loi M, Magallon-Baro A, Suker M, Van Eijck C, Hoogeman M, Nuyttens JJ. Daily dose to organs at risk predicts acute toxicity in pancreatic stereotactic radiotherapy. Acta Oncol 2020; 59:944-948. [PMID: 32207351 DOI: 10.1080/0284186x.2020.1742931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Mauro Loi
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Alba Magallon-Baro
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mustafa Suker
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Casper Van Eijck
- Department of Surgery, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Mischa Hoogeman
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Joost J. Nuyttens
- Department of Radiotherapy, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Raturi VP, Hojo H, Hotta K, Baba H, Takahashi R, Rachi T, Nakamura N, Zenda S, Motegi A, Tachibana H, Ariji T, Motegi K, Nakamura M, Okumura M, Hirano Y, Akimoto T. Radiobiological model-based approach to determine the potential of dose-escalated robust intensity-modulated proton radiotherapy in reducing gastrointestinal toxicity in the treatment of locally advanced unresectable pancreatic cancer of the head. Radiat Oncol 2020; 15:157. [PMID: 32571379 PMCID: PMC7310413 DOI: 10.1186/s13014-020-01592-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 12/31/2022] Open
Abstract
Background The purpose of this study was to determine the potential of escalated dose radiation (EDR) robust intensity-modulated proton radiotherapy (ro-IMPT) in reducing GI toxicity risk in locally advanced unresectable pancreatic cancer (LAUPC) of the head in term of normal tissue complication probability (NTCP) predictive model. Methods For 9 patients, intensity-modulated radiotherapy (IMRT) was compared with ro-IMPT. For all plans, the prescription dose was 59.4GyE (Gray equivalent) in 33 fractions with an equivalent organ at risk (OAR) constraints. Physical dose distribution was evaluated. GI toxicity risk for different endpoints was estimated using published NTCP Lyman Kutcher Burman (LKB) models for stomach, duodenum, small bowel, and combine stomach and duodenum (Stoduo). A Wilcoxon signed-rank test was used for dosimetry parameters and NTCP values comparison. Result The dosimetric results have shown that, with similar target coverage, ro-IMPT achieves a significant dose-volume reduction in the stomach, small bowel, and stoduo in low to high dose range in comparison to IMRT. NTCP evaluation for the endpoint gastric bleeding of stomach (10.55% vs. 13.97%, P = 0.007), duodenum (1.87% vs. 5.02%, P = 0.004), and stoduo (5.67% vs. 7.81%, P = 0.008) suggest reduced toxicity by ro-IMPT compared to IMRT. ∆NTCP IMRT – ro-IMPT (using parameter from Pan et al. for gastric bleed) of ≥5 to < 10% was seen in 3 patients (33%) for stomach and 2 patients (22%) for stoduo. An overall GI toxicity relative risk (NTCPro-IMPT/NTCPIMRT) reduction was noted (0.16–0.81) for all GI-OARs except for duodenum (> 1) with endpoint grade ≥ 3 GI toxicity (using parameters from Holyoake et al.). Conclusion With similar target coverage and better conformity, ro-IMPT has the potential to substantially reduce the risk of GI toxicity compared to IMRT in EDR of LAUPC of the head. 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 East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan.,Course of Advanced Clinical Research of Cancer, Graduate school of Medicine, Juntendo University, Tokyo, Japan
| | - Hidehiro Hojo
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Kenji Hotta
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Hiromi Baba
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Ryo Takahashi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Toshiya Rachi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Naoki Nakamura
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Sadamoto Zenda
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Atsushi Motegi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Hidenobu Tachibana
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Takaki Ariji
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Kana Motegi
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Masaki Nakamura
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Masayuki Okumura
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Yasuhiro Hirano
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Tetsuo Akimoto
- Division of Radiation Oncology and Particle therapy, National Cancer Center Hospital East, 6-5-1 chome, Kashiwanoha, Kashiwa-shi, Chiba-ken, 277-8577, Japan. .,Course of Advanced Clinical Research of Cancer, Graduate school of Medicine, Juntendo University, Tokyo, Japan.
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Lymph node–directed simultaneous integrated boost in patients with clinically lymph node–positive cervical cancer treated with definitive chemoradiotherapy: clinical outcomes and toxicity. ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s13566-020-00427-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Zheng Y, Gao W, Spratt DE, Sun Y, Xing L. Management of gastrointestinal perforation related to radiation. Int J Clin Oncol 2020; 25:1010-1015. [DOI: 10.1007/s10147-020-01662-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/12/2020] [Indexed: 12/15/2022]
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30
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Wang C, Xie J, Dong X, Mei L, Zhao M, Leng Z, Hu H, Li L, Gu Z, Zhao Y. Clinically Approved Carbon Nanoparticles with Oral Administration for Intestinal Radioprotection via Protecting the Small Intestinal Crypt Stem Cells and Maintaining the Balance of Intestinal Flora. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2020; 16:e1906915. [PMID: 32187855 DOI: 10.1002/smll.201906915] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 06/10/2023]
Abstract
The exploration of an old drug for new biomedical applications has an absolute predominance in shortening the clinical conversion time of drugs for clinical application. In this work, carbon nanoparticles suspension injection (CNSI), the first clinically approved carbon nanoparticles in China, is explored as a new nano-radioprotective agent for potent intestinal radioprotection. CNSI shows powerful radioprotective performance in the intestine under oral administration, including efficient free radical scavenging ability, good biosafety, high chemical stability, and relatively long retention time. For example, CNSI shows high reactive oxygen species (ROS) scavenging activities, which effectively alleviates the mitochondrial dysfunction and DNA double-strand breaks to protect the cells against radiation-induced damage. Most importantly, this efficient ROS scavenging ability greatly helps restrain the apoptosis of the small intestinal epithelial and crypt stem cells, which decreases the damage of the mechanical barrier and thus relieves radiation enteritis. Moreover, CNSI helps remove the free radicals in the intestinal microenvironment and thus maintain the balance of intestinal flora so as to mitigate the radiation enteritis. The finding suggests a new application of clinically approved carbon nanoparticles, which not only promotes the development of new intestinal radioprotector, but also has a great potential for clinical transformation.
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Affiliation(s)
- Chengyan Wang
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, and IHEP-HKU Joint Laboratory of Metallomics, Institute of High Energy Physics, Chinese Academy of Science, Beijing, 100049, China
- Center of Materials Science and Optoelectronics Engineering, College of Materials Science and Optoelectronic Technology, University of Chinese Academy of Science, Beijing, 100049, China
| | - Jiani Xie
- College of Pharmacy and Biological Engineering, Chengdu University, Chengdu, 610106, China
| | - Xinghua Dong
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, and IHEP-HKU Joint Laboratory of Metallomics, Institute of High Energy Physics, Chinese Academy of Science, Beijing, 100049, China
- Center of Materials Science and Optoelectronics Engineering, College of Materials Science and Optoelectronic Technology, University of Chinese Academy of Science, Beijing, 100049, China
| | - Linqiang Mei
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, and IHEP-HKU Joint Laboratory of Metallomics, Institute of High Energy Physics, Chinese Academy of Science, Beijing, 100049, China
- Center of Materials Science and Optoelectronics Engineering, College of Materials Science and Optoelectronic Technology, University of Chinese Academy of Science, Beijing, 100049, China
| | - Maoru Zhao
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, and IHEP-HKU Joint Laboratory of Metallomics, Institute of High Energy Physics, Chinese Academy of Science, Beijing, 100049, China
- Center of Materials Science and Optoelectronics Engineering, College of Materials Science and Optoelectronic Technology, University of Chinese Academy of Science, Beijing, 100049, China
| | - Zhengwei Leng
- Academician Workstation, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Houxiang Hu
- Academician Workstation, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637000, China
| | - Lele Li
- CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190, China
| | - Zhanjun Gu
- CAS Key Laboratory for Biomedical Effects of Nanomaterials and Nanosafety, and IHEP-HKU Joint Laboratory of Metallomics, Institute of High Energy Physics, Chinese Academy of Science, Beijing, 100049, China
- Center of Materials Science and Optoelectronics Engineering, College of Materials Science and Optoelectronic Technology, University of Chinese Academy of Science, Beijing, 100049, China
| | - Yuliang Zhao
- Center of Materials Science and Optoelectronics Engineering, College of Materials Science and Optoelectronic Technology, University of Chinese Academy of Science, Beijing, 100049, China
- CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology of China, Beijing, 100190, China
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George G, Lewis S, Chopra S, Phurailatpam R, Engineer R. A Retrospective Study of the Dosimetric Parameters and Duodenal Toxicity in Patients With Upper Gastrointestinal and Gynaecological Cancers Treated With Radiation Therapy. Clin Oncol (R Coll Radiol) 2020; 32:e53-e59. [DOI: 10.1016/j.clon.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/16/2019] [Accepted: 07/15/2019] [Indexed: 12/23/2022]
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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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Shortall J, Vasquez Osorio E, Chuter R, McWilliam A, Choudhury A, Kirkby K, Mackay R, van Herk M. Assessing localized dosimetric effects due to unplanned gas cavities during pelvic MR-guided radiotherapy using Monte Carlo simulations. Med Phys 2019; 46:5807-5815. [PMID: 31600837 DOI: 10.1002/mp.13857] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/01/2019] [Accepted: 10/01/2019] [Indexed: 01/28/2023] Open
Abstract
PURPOSE It has been proposed that beam modulation and opposing beam configurations can cancel effects of the Electron Return Effect (ERE) during MR-guided radiotherapy (MRgRT). However, this may not always be the case for unplanned gas cavities outside of the target in the pelvic region. We evaluate dosimetric effects, including effects in the rectal wall, due to unplanned spherical air cavities during MRgRT. METHODS Nine virtual cuboid water phantoms containing spherical air cavities (0.5-7.5 cm diameter) and a reference phantom without air were created. Monte Carlo dose calculations of 7 MV photons under the influence of a 1.5 T transverse magnetic field were produced using Monaco 5.19.02 Treatment Planning System (TPS) (Elekta AB, Stockholm, Sweden). Cavities in the path of a single and multiple beam plans were considered. Dose distributions of phantoms with and without air cavities were compared (ΔD% ) using a spherical coordinate system originating in the center of the cavity. Effects in the rectal wall were quantified by comparing dose volume histogram (DVH) parameters for solid and gaseous filling from simulated rectal wall structures. RESULTS Max(ΔD% ) of ~70% and 20% were observed around large cavities in the path of a single and multiple beam plans, respectively. Approximately 45 cm3 of phantom surrounding the largest cavity in a single beam received dose changes of >10%. Dmean in the rectal wall was unchanged when comparing gaseous and solid filling in the path of a single beam; however, D1cc and Dmax increased by up to ~45% and ~63%, respectively. CONCLUSIONS Unplanned gas cavities in the path of a single beam during pelvic MRgRT with a 1.5 T transverse magnetic field cause dose changes which may impact toxicity in the rectal wall, depending on local dose and fractionation. Effects are reduced but not eliminated with a five-beam plan.
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Affiliation(s)
- Jane Shortall
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Eliana Vasquez Osorio
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Robert Chuter
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Alan McWilliam
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Ananya Choudhury
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Karen Kirkby
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Ranald Mackay
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
| | - Marcel van Herk
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Medical Physics and Engineering, The Christie NHS Foundation Trust, Manchester, UK
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Yang B, Liu X, Hu K, Qiu J, Zhang F, Hou X, Yan J, Meng Q, Wang W, Yu L, Wang Y. Reduction of dose to duodenum with a refined delineation method of Para-aortic region in patients with locally advanced cervical Cancer receiving prophylactic extended-field radiotherapy. Radiat Oncol 2019; 14:196. [PMID: 31703705 PMCID: PMC6839216 DOI: 10.1186/s13014-019-1398-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 10/16/2019] [Indexed: 12/03/2022] Open
Abstract
Background To compare irradiation dose to the second and third portions of duodenum (Duo2 and Duo3) with a new refined and old delineation method of para-aortic region for patients with locally advanced cervical cancer (LACC) receiving prophylactic extended-field radiotherapy (EFRT). Methods Twenty consecutive patients with LACC were treated with prophylactic EFRT from January 2016 to January 2017 at our institute. Two delineation methods of para-aortic region were designed for each patient, the old delineation method ensured a full coverage of aortic and inferior vena cava, while the right paracaval region above L3 was omitted from CTV in the new delineation method. Patients received a dose of 50.4Gy in 28 fractions for PCTV and a dose of 60.2Gy in 28 fractions for PGTV with volumetric-modulated arc therapy (VMRT). The dose delivered to Duo2 and Duo3 with these two delineation methods were compared. Results All treatment plans achieved excellent target volume coverage with 95% of PCTV receiving 50.4Gy and 95% of PGTV receiving 60.2Gy. There was no difference between delineation methods in low dose level (V5, V10, V15, V20, V25) for Duo2 and Duo3. The V30, V35, V40, V45, V50, Dmax, Dmean and D2cc for Duo2 with the new and old delineation methods were 55.76% vs 80.54% (P = 0.009), 34.72% vs 70.91% (P < 0.001), 18.69% vs 55.46% (P < 0.001), 8.20% vs 41.49% (P < 0.001), 1.86% vs 21.60% (P < 0.001), 49.58Gy vs 52.91Gy (P = 0.002), 30.38Gy vs 39.22Gy (P = 0.001) and 37.90Gy vs 48.64Gy (P < 0.001) respectively. For Duo3, the new delineation method achieved significant advantages in V30, V35, V40, V45, V50 and Dmean over the old one (96.82% vs 99.25%, P = 0.021; 89.65% vs 97.21%, P = 0.001; 79.50% vs 93.18%, P < 0.001; 65.63% vs 82.93%, P < 0.001; 43.39% vs 65.60%, P < 0.001; 46.09Gy vs 49.24Gy, P < 0.001), no deference was observed regarding D2cc and Dmax with these two delineation methods. Conclusion With the new delineation method of para-aortic area in prophylactic EFRT, significant reduction of irradiation dose to the second and third portions of duodenum in high dose area was obtained. This may further lower the incidence of duodenal toxicity when performing prophylactic EFRT for patients with LACC.
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Affiliation(s)
- Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Xiaoliang Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Ke Hu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730.
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730.
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Qingyu Meng
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Weiping Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
| | - Yijun Wang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, NO.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, People's Republic of China, 100730
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Reyngold M, Parikh P, Crane CH. Ablative radiation therapy for locally advanced pancreatic cancer: techniques and results. Radiat Oncol 2019; 14:95. [PMID: 31171025 PMCID: PMC6555709 DOI: 10.1186/s13014-019-1309-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
Standard doses of conventionally fractionated radiation have had minimal to no impact on the survival duration of patients with locally advanced unresectable pancreatic cancer (LAPC). The use of low-dose stereotactic body radiation (SBRT) in 3- to 5-fractionshas thus far produced a modest improvement in median survival with minimal toxicity and shorter duration of treatment, but failed to produce a meaningful difference at 2 years and beyond. A much higher biologically effective dose (BED) is likely needed to achieve tumor ablation The challenge is the delivery of ablative doses near the very sensitive gastrointestinal tract. Advanced organ motion management, image guidance, and adaptive planning techniques enable delivery of ablative doses of radiation (> = 100Gy BED) when more protracted hypofractionated regimens or advanced image guidance and adaptive planning are used. This approach has resulted in encouraging improvements in survival in several studies. This review will summarize the evolution of the radiation technique over time from conventional to ablative and describe the practical aspects of delivering ablative doses near the GI tract using cone beam CT image (CBCT) guidance and online adaptive MRI guidance.
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Affiliation(s)
- Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Parag Parikh
- Department of Radiation Oncology, Henry Ford Cancer Institute, 2799 W Grand Blvd, Detroit, MI, 48202, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 300 East 65th St. Rm1509, New York, NY, 10065, USA.
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Fujimoto TN, Colbert LE, Huang Y, Molkentine JM, Deorukhkar A, Baseler L, de la Cruz Bonilla M, Yu M, Lin D, Gupta S, Cabeceiras PK, Kingsley CV, Tailor RC, Sawakuchi GO, Koay EJ, Piwnica-Worms H, Maitra A, Taniguchi CM. Selective EGLN Inhibition Enables Ablative Radiotherapy and Improves Survival in Unresectable Pancreatic Cancer. Cancer Res 2019; 79:2327-2338. [PMID: 31043430 PMCID: PMC6666414 DOI: 10.1158/0008-5472.can-18-1785] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 01/03/2019] [Accepted: 03/06/2019] [Indexed: 12/17/2022]
Abstract
When pancreatic cancer cannot be removed surgically, patients frequently experience morbidity and death from progression of their primary tumor. Radiation therapy (RT) cannot yet substitute for an operation because radiation causes fatal bleeding and ulceration of the nearby stomach and intestines before achieving tumor control. There are no FDA-approved medications that prevent or reduce radiation-induced gastrointestinal injury. Here, we overcome this fundamental problem of anatomy and biology with the use of the oral EGLN inhibitor FG-4592, which selectively protects the intestinal tract from radiation toxicity without protecting tumors. A total of 70 KPC mice with autochthonous pancreatic tumors received oral FG-4592 or vehicle control ± ablative RT to a cumulative 75 Gy administered in 15 daily fractions to a limited tumor field. Although ablative RT reduced complications from local tumor progression, fatal gastrointestinal bleeding was observed in 56% of mice that received high-dose RT with vehicle control. However, radiation-induced bleeding was completely ameliorated in mice that received high-dose RT with FG-4592 (0% bleeding, P < 0.0001 compared with vehicle). Furthermore, FG-4592 reduced epithelial apoptosis by half (P = 0.002) and increased intestinal microvessel density by 80% compared with vehicle controls. EGLN inhibition did not stimulate cancer growth, as treatment with FG-4592 alone, or overexpression of HIF2 within KPC tumors independently improved survival. Thus, we provide a proof of concept for the selective protection of the intestinal tract by the EGLN inhibition to enable ablative doses of cytotoxic therapy in unresectable pancreatic cancer by reducing untoward morbidity and death from radiation-induced gastrointestinal bleeding. SIGNIFICANCE: Selective protection of the intestinal tract by EGLN inhibition enables potentially definitive doses of radiation therapy. This might allow radiation to be a surgical surrogate for unresectable pancreatic cancer.Graphical Abstract: http://cancerres.aacrjournals.org/content/canres/79/9/2327/F1.large.jpg.
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Affiliation(s)
- Tara N Fujimoto
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lauren E Colbert
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yanqing Huang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jessica M Molkentine
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amit Deorukhkar
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura Baseler
- Department of Veterinary Medicine & Surgery, UT MD Anderson Cancer Center, Houston, Texas
| | - Marimar de la Cruz Bonilla
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Meifang Yu
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Lin
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sonal Gupta
- Department of Pathology, UT MD Anderson Cancer Center, Houston, Texas
- Department of Translational Molecular Pathology, UT MD Anderson Cancer Center, Houston, Texas
| | - Peter K Cabeceiras
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Charles V Kingsley
- Department of Imaging Physics, UT MD Anderson Cancer Center, Houston, Texas
| | - Ramesh C Tailor
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas
| | - Gabriel O Sawakuchi
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Helen Piwnica-Worms
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anirban Maitra
- Department of Pathology, UT MD Anderson Cancer Center, Houston, Texas
- Department of Translational Molecular Pathology, UT MD Anderson Cancer Center, Houston, Texas
| | - Cullen M Taniguchi
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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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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Jadon R, Higgins E, Hanna L, Evans M, Coles B, Staffurth J. A systematic review of dose-volume predictors and constraints for late bowel toxicity following pelvic radiotherapy. Radiat Oncol 2019; 14:57. [PMID: 30943992 PMCID: PMC6448293 DOI: 10.1186/s13014-019-1262-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 03/27/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Advanced pelvic radiotherapy techniques aim to reduce late bowel toxicity which can severely impact the lives of pelvic cancer survivors. Although advanced techniques have been largely adopted worldwide, to achieve their aim, knowledge of which dose-volume parameters of which components of bowel predict late bowel toxicity is crucial to make best use of these techniques. The rectum is an extensively studied organ at risk (OAR), and dose-volume predictors of late toxicity for the rectum are established. However, for other components of bowel, there is a significant paucity of knowledge. The Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) reviews recommend dose-volume constraints for acute bowel toxicity for peritoneal cavity and bowel loops, although no constraints are recommended for late toxicity, despite its relevance to our increasing number of survivors. This systematic review aims to examine the published literature to seek dose-volume predictors and constraints of late bowel toxicity for OARs (apart from the rectum) for use in clinical practice. METHODS A systematic literature search was performed using Medline, Embase, Cochrane Library, Web of Science, Cinahl and Pubmed. Studies were screened and included according to specific pre-defined criteria. Included studies were assessed for quality against QUANTEC-defined assessment criteria. RESULTS 101 studies were screened to find 30 relevant studies. Eight studies related to whole bowel, 11 to small bowel, and 21 to large bowel (including 16 of the anal canal). The anal canal is an important OAR for the development of late toxicity, and we recommend an anal canal Dmean <40Gy as a constraint to reduce late incontinence. For other components of bowel (sigmoid, large bowel, intestinal cavity, bowel loops), although individual studies found statistically significant parameters and constraints these findings were not corroborated in other studies. CONCLUSIONS The anal canal is an important OAR for the development of late bowel toxicity symptoms. Further validation of the constraints found for other components of bowel is needed. Studies that were more conclusive included those with patient-reported data, where individual symptom scores were assessed rather than an overall score, and those that followed statistical and endpoint criteria as defined by QUANTEC.
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Affiliation(s)
- Rashmi Jadon
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK. .,Department of Clinical Oncology, Addenbrookes' Hospital, Box 193, Cambridge, CB2 0QQ, UK.
| | - Emma Higgins
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - Louise Hanna
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - Mererid Evans
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - Bernadette Coles
- Cancer Research Wales Library, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
| | - John Staffurth
- Department of Clinical Oncology, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK.,School of Medicine, Institute of Cancer and Genetics, Cardiff University, Velindre Cancer Centre, Velindre Road, Whitchurch, Cardiff, CF14 2TL, UK
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Clinical safety and efficacy of salvage reirradiation for upper abdominal malignancies. Strahlenther Onkol 2019; 195:526-533. [PMID: 30689025 DOI: 10.1007/s00066-018-01420-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/22/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Reirradiation has the potential to provide effective local control of upper abdominal malignancies. This study aimed to evaluate the safety and efficacy of reirradiation for upper abdominal malignancies. METHODS A total of 42 patients with a history of prior radiotherapy (RT) received reirradiation for abdominal malignancies between 2005 and 2017. Each patient's medical records, contours, and dose distribution for both RT courses were reviewed. The median dose of the prior RT was 50.0 Gy (range, 30.0-60.0 Gy) and the median dose of reirradiation was 45.0 Gy (range, 15.0-75.0 Gy). RESULTS With a median follow-up of 10.9 months, the median infield-failure-free survival (IFFS) rate was 9.2 months. Gross tumor volume (GTV) significantly related to IFFS in both the univariate (p = 0.009) and multivariate analyses (p = 0.024), and patients with a GTV of <60.0 mL had an improved IFFS (p = 0.001). Four patients experienced ≥grade 3 late toxicities. In the retrospective dose reconstruction analysis in these patients, the cumulative dose to the most exposed 2 cc (D2cc) of the duodenum was >60.0 Gy (range, 60.1-73.7 Gy). In the univariate analysis, the D2cc of the duodenum and a preexisting duodenal ulcer identified using endoscopy prior to reirradiation significantly correlated with late severe toxicity (p = 0.021 and 0.017, respectively). CONCLUSIONS Reirradiation for upper abdominal malignancies could be safely performed for patients without preexisting gastrointestinal morbidity unless the duodenum received excessive radiation doses. Reirradiation could also provide substantial IFFS, especially for patients with a GTV of <60.0 mL.
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Nakamura A, Hiraoka M, Itasaka S, Nakamura M, Akimoto M, Ishihara Y, Mukumoto N, Goto Y, Kishi T, Yoshimura M, Matsuo Y, Yano S, Mizowaki T. Evaluation of Dynamic Tumor-tracking Intensity-modulated Radiotherapy for Locally Advanced Pancreatic Cancer. Sci Rep 2018; 8:17096. [PMID: 30459454 PMCID: PMC6244273 DOI: 10.1038/s41598-018-35402-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/05/2018] [Indexed: 12/25/2022] Open
Abstract
Intensity-modulated radiotherapy (IMRT) is now regarded as an important treatment option for patients with locally advanced pancreatic cancer (LAPC). To reduce the underlying tumor motions and dosimetric errors during IMRT as well as the burden of respiratory management for patients, we started to apply a new treatment platform of the dynamic tumor dynamic tumor-tracking intensity-modulated radiotherapy (DTT-IMRT) using the gimbaled linac, which can swing IMRT toward the real-time tumor position under patients' voluntary breathing. Between June 2013 and March 2015, ten patients were treated, and the tumor-tracking accuracy and the practical benefits were evaluated. The mean PTV size in DTT-IMRT was 18% smaller than a conventional ITV-based PTV. The root-mean-squared errors between the predicted and the detected tumor positions were 1.3, 1.2, and 1.5 mm in left-right, anterior-posterior, and cranio-caudal directions, respectively. The mean in-room time was 24.5 min. This high-accuracy of tumor-tracking with reasonable treatment time are promising and beneficial to patients with LAPC.
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Affiliation(s)
- Akira Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiro Hiraoka
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Satoshi Itasaka
- Department of Radiation Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Mitsuhiro Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mami Akimoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshitomo Ishihara
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobutaka Mukumoto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoko Goto
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takahiro Kishi
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michio Yoshimura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinsuke Yano
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takashi Mizowaki
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Abstract
Standard palliative doses of radiation for locally advanced unresectable pancreatic cancer have had minimal to no impact on survival. Randomized trials evaluating these palliative doses have not shown a significant survival benefit with the use of radiation as consolidation after chemotherapy. Results from nonrandomized studies of 3- to 5-fraction low-dose stereotactic radiation (SBRT) have likewise had a minimal impact, but with less toxicity and a shorter treatment time. Doses of SBRT have been reduced to half the level that is necessary (biological equivalent dose, BED of 53 Gy) to achieve tumor ablation in the treatment of other solid tumors (100 Gy BED) to protect the gastrointestinal (GI) tract. The survival benefit of these palliative options is modest. In contrast, ablative doses of radiation (100 Gy BED) can be delivered using the same SBRT technique in 15 to 25 fractions. In addition to precision tumor targeting and solutions for respiratory motion as with SBRT, the delivery of ablative doses takes advantage of heterogeneous dosing, increased fractionation, which allows higher doses to be given, as well as adaptive planning to address day-to-day GI tract motion in selected cases. These higher doses have resulted in encouraging long-term survival results in multiple studies. In this review, we discuss the critical concepts and components of techniques that can be used to deliver ablative radiotherapy doses for patients with pancreatic tumors: fractionation, intentional dose heterogeneity, respiratory gating, image guidance, and adaptive planning.
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Holyoake DLP, Warren DR, Hurt C, Aznar M, Partridge M, Mukherjee S, Hawkins MA. Stomach Dose-Volume Predicts Acute Gastrointestinal Toxicity in Chemoradiotherapy for Locally Advanced Pancreatic Cancer. Clin Oncol (R Coll Radiol) 2018; 30:418-426. [PMID: 29602584 DOI: 10.1016/j.clon.2018.02.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/05/2018] [Accepted: 02/27/2018] [Indexed: 01/06/2023]
Abstract
AIMS Gastrointestinal toxicity impedes dose escalation in chemoradiotherapy for hepatobiliary malignancies. Toxicity risk depends on clinical and radiotherapy metrics. We aimed to identify predictive factors using data from two prospective phase II clinical trials of locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Ninety-one patients with available data from the ARCII (59.4 Gy in 33 fractions with gemcitabine, cisplatin and nelfinavir, n = 23) and SCALOP (50.4 Gy in 28 fractions with capecitabine or gemcitabine, n = 74) trials were studied. The independent variables analysed comprised age, sex, performance status, baseline symptoms, tumour size, weight loss, chemotherapy regimen and dose-volume histogram of stomach and duodenum in 5 Gy bins. The outcome measures used were Common Terminology Criteria of Adverse Events (CTCAE) grade and risk of CTCAE grade ≥2 acute upper gastrointestinal toxicity (anorexia, pain, nausea and/or vomiting). The risk of CTCAE grade ≥2 events was modelled using multivariable logistic regression and prediction of severity grade using ordinal regression. RESULTS CTCAE grade ≥2 symptoms occurred in 38 patients (42%). On univariate analysis, stomach V35-45Gy was predictive of risk (odds ratio 1.035, 95% confidence interval 1.007-1.063) and grade (1.023, 1.003-1.044) of toxicity. The area under the curve was 0.632 (0.516-0.747) with toxicity risk 33/66 (50%) above and 5/25 (20%) below the optimal discriminatory threshold (7.1 cm3). Using a threshold of 30 cm3, risk was 13/20 (65%) versus 25/71 (35%). The optimal multivariable logistic regression model incorporated patient sex, chemotherapy regimen and stomach V35-45Gy. Receiving gemcitabine rather than capecitabine (odds ratio 3.965, 95% confidence interval 1.274-12.342) and weight loss during induction chemotherapy (1.216, 1.043-1.419) were significant predictors for the SCALOP cohort, whereas age predicted toxicity risk in ARCII only (1.344, 1.015-1.780). Duodenum dose-volume did not predict toxicity risk or severity in any cohort. CONCLUSIONS In chemoradiotherapy for LAPC the volume of stomach irradiated to a moderately high dose (35-45 Gy) predicts the incidence and severity of acute toxicity. Other predictive factors can include age, sex, recent weight loss and concomitant chemotherapy agents.
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Affiliation(s)
- D L P Holyoake
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - D R Warren
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - C Hurt
- Centre for Trials Research, Cardiff University, Cardiff, Wales, UK
| | - M Aznar
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - M Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - S Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Dreher C, Habermehl D, Jäkel O, Combs SE. Effective radiotherapeutic treatment intensification in patients with pancreatic cancer: higher doses alone, higher RBE or both? Radiat Oncol 2017; 12:203. [PMID: 29282139 PMCID: PMC5745986 DOI: 10.1186/s13014-017-0945-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 12/14/2017] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer, especially in case of locally advanced stage has a poor prognosis. Radiotherapy in general can lead to tumor volume reduction, but further improvements, such as ion beam therapy have to be promoted in order to enable dose escalation, which in turn results in better local control rates and downsizing of the tumor itself. Ion beam therapy with its highly promising physical properties is also accompanied by distinct inter- and intrafractional challenges in case of robustness. First clinical results are promising, but further research in motion mitigation and biological treatment planning is necessary, in order to determine the best clinical rationales and conditions of ion beam therapy of pancreatic cancer. This review summarizes the current knowledge and studies on ion beam therapy of pancreatic cancer.
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Affiliation(s)
- Constantin Dreher
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22 Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22 Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site München, München, Germany
| | - Oliver Jäkel
- Department of Medical Physics in Radiation Oncology, German Cancer Research Center, INF, 280 Heidelberg, Germany
- Heidelberg Ion Beam Therapy Center (HIT), INF 450, 69120 Heidelberg, Germany
| | - Stephanie E. Combs
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22 Munich, Germany
- Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Oberschleißheim, Germany
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site München, München, Germany
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Dose-escalated radiotherapy for unresectable or locally recurrent pancreatic cancer: Dose volume analysis, toxicity and outcome of 28 consecutive patients. PLoS One 2017; 12:e0186341. [PMID: 29023527 PMCID: PMC5638513 DOI: 10.1371/journal.pone.0186341] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/01/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The role of radiotherapy for unresectable pancreatic cancer is controversial. A benefit of additional radiotherapy is supported by some observations. A dose-effect relationship was recently found by dose escalation employing image guided and intensity modulated radiotherapy. METHODS We retrospectively evaluated 28 consecutive patients, all with history of extensive prior therapies for unresectable locally advanced/ recurrent pancreatic cancer (LAPC/LRPC). Treatment was delivered by helical tomotherapy after daily position verification with computed tomography. Dose to the planned target volume (PTV) was 51 Gy, while the dose to the macroscopic tumor was escalated by a simultaneous integrated boost to a median cumulative dose of 66 Gy (60-66 Gy). Concomitant chemotherapy consisted mainly of capecitabine (n = 23). RESULTS 10 of 28 patients presented acute toxicities > grade 2, one patient succumbed to gastrointestinal bleeding after treatment. No correlations of toxicities and dose volume histograms (DVH) of retrospectively delineated small bowel loops were observed, although average small bowel volume receiving ≥ 20 Gy was 374 ml. DVH analyses revealed a correlation of splenic parameters and acute toxicity: Vomiting, anorexia, dehydration, hematologic toxicity, fatigue, combined gastro-intestinal toxicity wit R-values between 0.392 and 0.561 (all p-values > 0.05). Only one patient developed late toxicities > grade 2. With an average follow-up time in surviving patients of 14 months median overall survival time was 19 months and median time to local recurrence 13 months. In 8 patients with available imaging of local recurrence: 5 in field recurrences, 2 marginal recurrences and one lymph node recurrence outside the high dose radiation field were observed. In univariate analysis only ΔCA-19-9 during radiotherapy was associated with local control (p = 0.029) and overall survival (p = 0.049). CONCLUSION Dose escalated normo-fractionated radiotherapy for LAPC/LRPC seems feasible and suitable to prolong local control and in consequence long-term survival. However, in-field local progression is still frequently observed and possibilities to increase the local effectiveness should be evaluated. Exposure of the spleen was predictive for acute toxicity and should be further investigated.
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Yamashita S, Overman MJ, Wang H, Zhao J, Okuno M, Goumard C, Tzeng CW, Kim M, Fleming JB, Vauthey JN, Katz MH, Lee JE, Conrad C. Pathologic Response to Preoperative Therapy as a Novel Prognosticator for Ampullary and Duodenal Adenocarcinoma. Ann Surg Oncol 2017; 24:3954-3963. [PMID: 28980211 DOI: 10.1245/s10434-017-6098-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognostic impact of pathologic response to preoperative therapy on patients with duodenal adenocarcinoma (DA) and ampullary adenocarcinoma (AMPA) has not been established. METHODS A retrospective review of 266 patients who underwent curative resection for DA (n = 97) or AMPA (n = 169) during 1993-2015 was performed. For patients who underwent preoperative therapy, the pathologic response was systematically evaluated and classified as major (0-49% of viable residual tumor cells) or minor (≥ 50% of viable residual tumor cells). Uni- and multivariable analyses were performed to identify predictors of pathologic response and disease-specific survival (DSS). RESULTS For the 79 patients treated with preoperative therapy (DA: n = 34; AMPA: n = 45), concomitant use of radiation (80%, 67/79) was the sole independent predictor of major pathologic response (odds ratio [OR] 8.17; 95% confidence interval [CI] 1.85-58.2; P = 0.005). The patients with major pathologic response had a better 5-year DSS rate than the patients with minor pathologic response (DA: 65 vs 25%; P = 0.028; AMPA: 85 vs 43%; P = 0.016). In the multivariable analysis of DSS for the 79 patients who underwent preoperative therapy, major pathologic response was the sole predictor of improved DSS (hazard ratio [HR] 2.88; 95% CI 1.41-5.98; P = 0.004). In the multivariable analysis of DSS for the entire cohort, pathologic stage 2 or lower was the sole predictor of better DSS. CONCLUSION The major pathologic response to preoperative therapy predicted improved DSS after resection of DA and AMPA and might represent a new prognosticator after resection of DA and AMPA.
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Affiliation(s)
- Suguru Yamashita
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael J Overman
- Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huamin Wang
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Zhao
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Masayuki Okuno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claire Goumard
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Ling A, Furhang E, Ryemon SN, Ennis RD. Late small bowel toxicity after aggressive abdominopelvic intensity modulated radiation therapy. Adv Radiat Oncol 2017; 2:615-623. [PMID: 29204529 PMCID: PMC5707426 DOI: 10.1016/j.adro.2017.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/17/2017] [Accepted: 09/06/2017] [Indexed: 12/24/2022] Open
Abstract
Purpose We retrospectively analyzed late small bowel toxicity in patients who received abdominal or pelvic intensity modulated radiation therapy (IMRT) to the small bowel with a maximum dose greater than the generally accepted maximal tolerable dose of 45 Gy. Methods and materials All patients (N = 94) who received IMRT with a point dose of at least 45 Gy to tightly contoured small bowel between 2005 and 2014 at our institution were included. The median prescribed treatment dose was 70.2 Gy. The median follow-up was 20.1 months. Late small bowel toxicity was assessed using the Common Terminology Criteria for Adverse Events Version 3.0. Dosimetric variables and clinical factors were assessed for their relationship to small bowel toxicity. Results The median maximal small bowel point dose (Dmax) was 6546.5 cGy. The estimated 5-year rates of freedom from at least grade 1, at least grade 2, and at least grade 3 late small bowel toxicity were 72.4% (95% confidence interval [CI], 60.7%-86.5%), 91.9% (95% CI, 84.1%-100%), and 93.6% (95% CI, 86.2%-100%), respectively. One patient (1.1%) developed grade 3 late toxicity, and 2 patients (2.1%) developed grade 4 late toxicity. Use of capecitabine/5-fluorouracil treatment was a significant predictor (P < 0.001) of at least grade 1 and at least grade 2 small bowel toxicity. No other clinical factors were associated with toxicity. None of the dose-volume parameters were significant predictors of small bowel toxicity. Conclusion It may be possible with IMRT to deliver high doses to small volumes of small bowel with low rates of significant long-term complications. Further studies should explore tolerable dose-volume relationships in cases in which aggressive abdominal or pelvic treatment may be warranted to treat the underlying malignancy.
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Affiliation(s)
- Andrew Ling
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Eli Furhang
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Shannon N Ryemon
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York
| | - Ronald D Ennis
- Department of Radiation Oncology, Mount Sinai West Hospital, New York, New York.,Icahn School of Medicine at Mount Sinai, New York, New York
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Stereotactic Body Radiation Therapy (SBRT) Combined With Chemotherapy for Unresected Pancreatic Adenocarcinoma. Am J Clin Oncol 2017; 40:152-157. [PMID: 25171298 PMCID: PMC4418949 DOI: 10.1097/coc.0000000000000118] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objectives: The role of radiation therapy in the management of unresectable pancreatic cancer is controversial. One concern about concurrent chemoradiation relates to the timing of chemotherapy. In contrast to conventional radiation therapy, stereotactic body radiation therapy (SBRT) delivers high doses in a shorter duration resulting in minimal disruption in chemotherapy. Here, we report our results of patients treated with SBRT and chemotherapy for inoperable pancreatic cancer. Materials and Methods: Thirty-eight patients treated with SBRT and chemotherapy for locally advanced, borderline resectable, and medically inoperable pancreatic cancer at our institution from January 2008 to December 2012 were included in this retrospective analysis. Treatment was delivered in 5 fractions of 5 or 6 Gy per fraction over 5 days. Toxicities were scored using the Common Terminology Criteria for Adverse Events version 3. Survival was calculated using the Kaplan-Meier method. Results: The median age was 70 years (range, 45 to 90 y). Eastern Cooperative Oncology Group performance status ranged from 0 to 3. Thirty-four patients received concurrent chemotherapy. Four patients received sequential chemotherapy. Median overall survival was 14.3 months and median progression-free survival was 9.2 months from diagnosis. From radiation, overall survival and progression-free survival were 12.3 and 6.8 months, respectively. The overall local control rate was 79%. Acute toxicity was minimal. Severe late SBRT-related toxicities included 1 grade 3 gastric outlet obstruction, 1 grade 4 biliary stricture, and 1 grade 5 gastric hemorrhage. Conclusions: SBRT combined with chemotherapy for unresectable pancreatic cancer is convenient, feasible, and generally well tolerated. Outcomes of SBRT combined with chemotherapy compare favorably to results obtained with chemotherapy and conventional radiation therapy.
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Modelling duodenum radiotherapy toxicity using cohort dose-volume-histogram data. Radiother Oncol 2017; 123:431-437. [PMID: 28600084 PMCID: PMC5486774 DOI: 10.1016/j.radonc.2017.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 12/25/2022]
Abstract
Background and purpose Gastro-intestinal toxicity is dose-limiting in abdominal radiotherapy and correlated with duodenum dose-volume parameters. We aimed to derive updated NTCP model parameters using published data and prospective radiotherapy quality-assured cohort data. Material and methods A systematic search identified publications providing duodenum dose-volume histogram (DVH) statistics for clinical studies of conventionally-fractionated radiotherapy. Values for the Lyman-Kutcher-Burman (LKB) NTCP model were derived through sum-squared-error minimisation and using leave-one-out cross-validation. Data were corrected for fraction size and weighted according to patient numbers, and the model refined using individual patient DVH data for two further cohorts from prospective clinical trials. Results Six studies with published DVH data were utilised, and with individual patient data included outcomes for 531 patients in total (median follow-up 16 months). Observed gastro-intestinal toxicity rates ranged from 0% to 14% (median 8%). LKB parameter values for unconstrained fit to published data were: n = 0.070, m = 0.46, TD50(1) [Gy] = 183.8, while the values for the model incorporating the individual patient data were n = 0.193, m = 0.51, TD50(1) [Gy] = 299.1. Conclusions LKB parameters derived using published data are shown to be consistent to those previously obtained using individual patient data, supporting a small volume-effect and dependence on exposure to high threshold dose.
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Wilson JM, Mukherjee S, Brunner TB, Partridge M, Hawkins MA. Correlation of 18F-Fluorodeoxyglucose Positron Emission Tomography Parameters with Patterns of Disease Progression in Locally Advanced Pancreatic Cancer after Definitive Chemoradiotherapy. Clin Oncol (R Coll Radiol) 2017; 29:370-377. [PMID: 28190636 PMCID: PMC5429392 DOI: 10.1016/j.clon.2017.01.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 01/09/2017] [Accepted: 01/17/2017] [Indexed: 12/13/2022]
Abstract
AIMS A proportion of patients with pancreatic cancer never develop metastatic disease. We evaluated a role for 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in identifying a subset of patients with locally advanced pancreatic cancer (LAPC) who never develop metastatic disease and only experience local disease and may therefore benefit from local treatment intensification. MATERIAL AND METHODS Patients with histologically confirmed LAPC entered a single-centre phase II study of definitive upfront chemoradiotherapy (CRT). All patients underwent FDG-PET/CT before and 6 weeks after CRT. Tumour volume, standardised uptake values (SUVmax, SUVpeak, SUVmean, SUVmedian) and total lesion glycolysis (TLG) were measured on each scan and the response in each parameter was evaluated. The presence or absence of metastatic disease was noted on contrast-enhanced CT carried out every 3 months for 1 year and then at clinician discretion. RESULTS Twenty-three patients with LAPC were recruited; 17/23 completed treatment and had interpretable sequential imaging. Twenty-four per cent of patients only ever experienced local disease. Median pre-CRT FDG-PET parameters were significantly lower in patients with local disease only during follow-up compared with those who developed metastatic disease: SUVmax 3.8 versus 8.6 (P=0.006), SUVpeak 2.5 versus 7.5 (P=0.002), SUVmean 1.8 versus 3.3 (P=0.001), SUVmedian 1.7 versus 3.0 (P=0.002), TLG 26.9 versus 115.9 (P=0.006). Tumour volume, post-CRT FDG-PET values and their relative change were not statistically different between local disease and metastatic disease groups. Receiver operating characteristic curves for pre-CRT FDG-PET parameters to predict those who never develop metastatic disease all had areas under the curve (AUCs) ≥ 0.932. Pre-CRT FDG-PET SUVmax < 6.2 predicted patients with local disease only during follow-up with 100.0% sensitivity and 92.3% specificity, 80.0% positive predictive value and 100% negative predictive value. CONCLUSIONS Our findings suggest that patients with less FDG-avid tumours are less likely to metastasise and may therefore benefit from upfront local treatment intensification.
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Affiliation(s)
- J M Wilson
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK.
| | - S Mukherjee
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK
| | - T B Brunner
- Department of Radiation Oncology, University Hospitals Freiburg, Freiburg im Breisgau, Germany
| | - M Partridge
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK
| | - M A Hawkins
- CRUK/MRC Oxford Institute for Radiation Oncology, Gray Laboratories, Oxford, UK
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Lee J, Lim DH, Park HC, Yu JI, Choi DW, Choi SH, Heo JS. Predictive factors of gastroduodenal bleeding after postoperative radiotherapy in biliary tract cancer. Jpn J Clin Oncol 2017; 47:328-333. [PMID: 28064203 DOI: 10.1093/jjco/hyw205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/22/2016] [Indexed: 12/20/2022] Open
Abstract
Objective To identify predictive factors for gastroduodenal bleeding after postoperative radiation therapy in patients with biliary tract cancer. Methods We identified 186 patients with biliary tract cancer who completed scheduled postoperative radiation therapy from March 2000 to August 2013. To isolate the effects of radiation on gastroduodenal bleeding, patients with pylorus-preserving pancreaticoduodenectomy, pylorus-resecting pancreaticoduodenectomy or Whipple surgery (n = 67) were excluded from this analysis. Postoperative radiation therapy was started at a median 5 weeks (range: 4-12 weeks) after surgery with a median dose of 44 Gy (range: 44-54), and chemotherapy was also concurrently administered to 102 patients. Results The median age of the patients was 59 years (range: 36-76 years). Of the 119 patients, 26 had intrahepatic cholangiocarcinoma, 29 had hilar cholangiocarcinoma, while 64 had extrahepatic tumors (gallbladder cancer, n = 53; proximal bile duct cancer, n = 10; choledochal cyst cancer, n = 1). Of all, 11 patients (9%) developed gastroduodenal bleeding. In univariate analyses, hepatic artery resection and gastroduodenal wall thickening on postoperative radiation therapy simulation computed tomography were statistically significant factors for gastroduodenal bleeding. Multivariate analysis by a logistic regression model using those two variables revealed that both parameters were independent predictors for gastroduodenal bleeding. Conclusions Concomitant hepatic artery resection and presence of gastroduodenal wall thickening on postoperative radiation therapy simulation computed tomography were predictive factors for gastroduodenal bleeding after postoperative radiation therapy in biliary tract cancer. In such cases, patients should be informed of the high risk of gastroduodenal bleeding, and should be closely observed during and after postoperative radiation therapy.
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Affiliation(s)
- Jieun Lee
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Departments of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ho Choi
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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