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Bronk JK, McAleer MF, McGovern SL, Lassen-Ramshad Y, Safwat A, Daw NC, Rainusso N, Mahajan A, Grosshans DR, Paulino AC. Comprehensive radiotherapy for pediatric Ewing Sarcoma: Outcomes of a prospective proton study. Radiother Oncol 2024; 195:110270. [PMID: 38583721 DOI: 10.1016/j.radonc.2024.110270] [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: 10/23/2023] [Revised: 03/20/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND PURPOSE Patients with Ewing Sarcoma (EWS) are treated with multimodality therapy which includes radiation therapy (RT) as an option for local control. We report on the efficacy after proton radiation therapy (PRT) to the primary site for localized and metastatic EWS. MATERIALS AND METHODS Forty-two children with EWS (33 localized, 9 metastatic) treated between 2007 and 2020 were enrolled on 2 prospective registry protocols for pediatric patients undergoing PRT. PRT was delivered by passive scatter (74 %), pencil-beam scanning (12 %) or mixed technique (14 %). Treated sites included the spine (45 %), pelvis/sacrum (26 %), skull/cranium (14 %), extraosseous (10 %), and chest wall (5 %). Median radiation dose was 54 Gy-RBE (range 39.6-55.8 Gy-RBE). Patients with metastatic disease received consolidative RT to metastatic sites (4 at the time of PRT to the primary site, 5 after completion of chemotherapy). Median follow-up time was 47 months after PRT. RESULTS The 4-year local control (LC), progression-free survival (PFS), and overall survival (OS) rates were 83 %, 71 %, and 86 %, respectively. All local failures (n = 6) were in-field failures. Tumor size ≥ 8 cm predicted for inferior 4-year LC (69 % vs 95 %, p = 0.04). 4-year PFS and OS rates were not statistically different in patients with localized versus metastatic disease (72 % vs 67 %, p = 0.70; 89 % vs 78 %, p = 0.38, respectively). CONCLUSION In conclusion, LC for pediatric patients with EWS treated with PRT was comparable to that of historical patients who received photon-RT. Tumor size ≥ 8 cm predicted increased risk of local failure. Patients with metastatic disease, including non-pulmonary only metastases, received radiation therapy to all metastatic sites and had favorable survival outcomes.
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Affiliation(s)
- Julianna K Bronk
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Mary Frances McAleer
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Susan L McGovern
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | | | - Akmal Safwat
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Najat C Daw
- Department of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nino Rainusso
- Department of Pediatrics, Division of Hematology-Oncology, Baylor College of Medicine and Texas Children's Hospital Cancer and Hematology Centers, Houston, TX, United States
| | - Anita Mahajan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, United States
| | - David R Grosshans
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Arnold C Paulino
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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Mahata A, Chakraborty S, Mandal S, Achari RB, Bhattacharyya T, Mallick I, Arunsingh M, Chatterjee S. Quality Assurance in Radiotherapy (RT)-Specific Trials: Indian Scenario. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00211-5. [PMID: 38897901 DOI: 10.1016/j.clon.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024]
Abstract
AIMS There is evidence that proper radiotherapy trial quality assurance (RTTQA) translates into improved outcomes for patients. However, the practice of RTTQA is heterogeneous and implemented in a diverse manner across trials. In this paper, we review the RTTQA report for randomised trials (RCT) conducted in India and present our experience with RTTQA for various clinical trials and highlight the key achievements and challenges. MATERIALS AND METHODS Search was performed using the keywords and the variations thereof for "radiotherapy" and author affiliations from India, its states and major metropolitan cities. Pubmed search filters were used to restrict results to RCT published in the past 5 years (2019-2024). Reporting of RTTQA procedures from publications and protocols was documented along with the protocol-specified dosimetric goals. We also evaluated a few clinical trials performed in the Department of Radiation Oncology at Tata Medical Center. The different RTTQA procedures and results for four representative clinical trials have been described. RESULTS A formal RTTQA process was reported by only one out of 24 randomised controlled trials and formal dosimetric goals were pre-specified by 9 of 13 trials where IMRT was used as treatment. RTTQA requirements were tailored for each clinical trial at Tata Medical Center. For the HYPORT trial, the RTTQA process focused on ensuring the matchline doses were homogenous. HYPORT B trial commissioned the use of a simultaneous integrated boost technique which emphasised conformal avoidance of dose spillage to contralateral breast and lung. HYPORT Adjuvant and PROPARA trials are multicentre clinical trials. While HYPORT Adjuvant focussed on ensuring that the dose delivery met the predefined constraints, segmentation of the target volume was important for the PROPARA trial. CONCLUSION We demonstrate different RTTQA procedures required for representative clinical trials and highlight key challenges encountered.
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Affiliation(s)
- A Mahata
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - S Chakraborty
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India.
| | - S Mandal
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - R B Achari
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - T Bhattacharyya
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - I Mallick
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - M Arunsingh
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
| | - S Chatterjee
- Department of Radiation Oncology, Tata Medical Center, Kolkata, West Bengal, 700156, India
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Kacar M, Nagel MB, Liang J, Li Y, Neel MD, Lucas JT, McCarville MB, Santiago T, Pappo AS, Krasin MJ. Radiation therapy dose escalation achieves high rates of local control with tolerable toxicity profile in pediatric and young adult patients with Ewing sarcoma. Cancer 2024; 130:1836-1843. [PMID: 38271232 PMCID: PMC11058012 DOI: 10.1002/cncr.35196] [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: 09/13/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Local control for patients with Ewing sarcoma (EWS) who present with large tumors are suboptimal when treated with standard radiation therapy (RT) doses of 54-55.8 Gy. The purpose of this study is to determine local control and toxicity of dose-escalated RT for tumors ≥8 cm (greatest diameter at diagnosis) in pediatric and young adult patients with EWS. METHODS Eligible patients ≤30 years old with newly diagnosed EWS ≥8 cm treated with definitive conformal or intensity modulated photon, or proton radiation therapy techniques were included. All patients in the study received dose-escalated RT doses. Outcomes included overall survival (OS), event-free survival (EFS), local failure rates, and toxicity. RESULTS Thirty-two patients were included, 20 patients presented with metastatic disease and 12 patients with localized disease. The median RT dose was 64.8 Gy (range, 59.4-69.4 Gy) with variability of doses to protect normal surrounding tissues. All patients received systemic chemotherapy. The 5-year OS and EFS for the cohort was 64.2% and 42%, respectively. The 5-year cumulative incidence of local failure was 6.6%. There were two combined local and distant failures with no isolated local failures. Twenty-nine patients experienced short term toxicity, 90% of those being radiation dermatitis. Twenty-seven patients experienced long-term toxicity, with only one experiencing grade 4 toxicity, a secondary malignancy after therapy. CONCLUSION This study demonstrates that definitive RT for pediatric and young adult patients with EWS ≥8 cm provides high rates of local control, while maintaining a tolerable toxicity profile.
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Affiliation(s)
- Marija Kacar
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Margaret B. Nagel
- Department of Pediatrics, UT Southwestern Medical Center Dallas, Dallas, Texas, USA
| | - Jia Liang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Yimei Li
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Michael D. Neel
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - John T. Lucas
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - M. Beth McCarville
- Department of Diagnostic Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Teresa Santiago
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Alberto S. Pappo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Matthew J. Krasin
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Li X, Qi S, Zhu T, Jiang Y, Wang W. Primary mediastinum Ewing's sarcoma with pleural effusion: A case report and literature review. Open Life Sci 2023; 18:20220669. [PMID: 37554964 PMCID: PMC10404896 DOI: 10.1515/biol-2022-0669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/11/2023] [Accepted: 07/06/2023] [Indexed: 08/10/2023] Open
Abstract
Ewing's sarcoma (ES) is an aggressive cancer in young adults. Primary ES occurring in the chest with pleural effusion is even rarer. We report the case of a 15-year-old girl who presented with intermittent chest pain occurring for more than 2 months and cough and wheezing for 10 days. Radiological imaging showed a large soft tissue mass with multiple small vessel shadows near the left mediastinum and bloody pleural effusion in the left thorax. ES was diagnosed by positive immunostaining for CD99, FLI-1, and NKX2 combined with fluorescence in situ hybridization detection of the EWSR1 gene arrangement. With chemotherapy, lung computed tomography revealed that the tumor had become much smaller, and the fluid was absorbed. We report a case of extraskeletal Ewing's sarcoma (EES) in the mediastinum with pleural effusion, which is unusual and challenging. EES is a highly malignant tumor with a poor prognosis. Early diagnosis and treatment can improve the survival rate of patients.
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Affiliation(s)
- Xuhong Li
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan430071, China
| | - Shan Qi
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan430071, China
| | - Taiwen Zhu
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan430071, China
| | - Ying Jiang
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan430071, China
| | - Wei Wang
- Department of Respiratory and Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan430071, China
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Akdag NNS, Gultekin M, Yildiz F. In Regard to Ahmed et al. Int J Radiat Oncol Biol Phys 2023; 116:960. [PMID: 37355310 DOI: 10.1016/j.ijrobp.2023.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 03/23/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Nur Nimet Saliha Akdag
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Melis Gultekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ferah Yildiz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Ahmed SK. In Reply to Akdag et al. Int J Radiat Oncol Biol Phys 2023; 116:960-961. [PMID: 37355311 DOI: 10.1016/j.ijrobp.2023.03.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona
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Nath J, Sarma G. In Regard to Laskar et al. Int J Radiat Oncol Biol Phys 2023; 115:260-261. [PMID: 36526394 DOI: 10.1016/j.ijrobp.2022.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/13/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Jyotiman Nath
- Department of Radiation Oncology, Dr B Borooah Cancer Institute, Guwahati, Assam, India
| | - Gautam Sarma
- Department of Radiation Oncology, Dr B Borooah Cancer Institute, Guwahati, Assam, India
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Polzer C, Dunst J. [Radiotherapy dose escalation in the treatment of unresectable Ewing sarcoma]. Strahlenther Onkol 2023; 199:204-207. [PMID: 36650309 PMCID: PMC9877040 DOI: 10.1007/s00066-023-02046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Affiliation(s)
- Constanze Polzer
- grid.412468.d0000 0004 0646 2097Klinik für Strahlentherapie Kiel, UKSH, Kiel, Deutschland
| | - Jürgen Dunst
- grid.412468.d0000 0004 0646 2097Klinik für Strahlentherapie Kiel, UKSH, Kiel, Deutschland
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Particle Therapy in Adult Patients with Pelvic Ewing Sarcoma-Tumor and Treatment Characteristics and Early Clinical Outcomes. Cancers (Basel) 2022; 14:cancers14246045. [PMID: 36551530 PMCID: PMC9775362 DOI: 10.3390/cancers14246045] [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: 11/01/2022] [Revised: 11/20/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To report dosimetric characteristics and early clinical outcomes in patients with pelvic Ewing sarcoma undergoing particle therapy. METHODS Patients ≥ 18 years old with pelvic Ewing sarcoma treated in adjuvant or definitive settings were considered for this retrospective analysis. Proton therapy was carried out with 45-60 Gy (RBE) (1.5-2 Gy (RBE) per fraction) and carbon ion therapy for recurrent disease with 51 Gy (RBE) (3 Gy (RBE) per fraction). Local control (LC), disease control (DC) and overall survival (OS) were calculated using the Kaplan-Meier method. RESULTS For our sample, 21 patients were available, 18 of whom were treated for primary, 3 for locally recurrent and 16 for inoperable disease. The median CTV and PTV were 1215 cm3 and 1630 cm3. Median Dmean values for the PTV, bladder and rectum and median V40 Gy for the bowel for patients undergoing proton therapy were 56 Gy (RBE), 0.6 Gy (RBE), 9 Gy (RBE) and 15 cm3, respectively. At the end of particle therapy, G 1-2 skin reactions (n = 16/21) and fatigue (n = 9/21) were the main reported symptoms. After a median follow-up of 21 months, the 2-year LC, DC and OS were 76%, 56% and 86%, respectively. CONCLUSIONS Particle therapy in adult pelvic Ewing sarcoma is feasible and provides excellent dosimetric results. First clinical outcomes are promising; however, further long-term follow-up is needed.
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Daley JD, Olson AC, Bailey KM. Harnessing immunomodulation during DNA damage in Ewing sarcoma. Front Oncol 2022; 12:1048705. [PMID: 36483025 PMCID: PMC9722957 DOI: 10.3389/fonc.2022.1048705] [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: 09/19/2022] [Accepted: 10/26/2022] [Indexed: 11/23/2022] Open
Abstract
Ewing sarcoma is a fusion-oncoprotein-driven primary bone tumor most commonly diagnosed in adolescents. Given the continued poor outcomes for patients with metastatic and relapsed Ewing sarcoma, testing innovative therapeutic approaches is essential. Ewing sarcoma has been categorized as a 'BRCAness' tumor with emerging data characterizing a spectrum of DNA damage repair defects within individual Ewing tumors, including the presence of EWSR1::FLI1 itself, recurrent somatic mutations, and rare germline-based defects. It is critical to understand the cumulative impact of various DNA damage repair defects on an individual Ewing tumor's response to therapy. Further, in addition to DNA-damage-directed therapies, subsets of Ewing tumors may be more susceptible to DNA-damage/immunotherapy combinations given the significant cross-talk between DNA damage and inflammatory pathways in the tumor microenvironment. Here we review potential approaches utilizing DNA-damaging agents as modulators of the Ewing tumor immune microenvironment, with a focus on radiation and opportunities during disease metastasis and relapse.
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Affiliation(s)
- Jessica D. Daley
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Adam C. Olson
- Department of Radiation Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kelly M. Bailey
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States,Cancer Immunology and Immunotherapy Program, UPMC Hillman Cancer Center, Pittsburgh, PA, United States,*Correspondence: Kelly M. Bailey,
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Simões R, Jayaprakash K. OncoFlash – Research Updates in a Flash! (August 2022). Clin Oncol (R Coll Radiol) 2022. [DOI: 10.1016/j.clon.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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