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Bhutani MS, Narang AK, Ding K, Casey B, Krishnan K, Koay EJ, Hong TS, Herman JM, Griffin KH, Shin EJ. EUS-guided hydrogel injection to separate pancreatic head carcinoma from duodenum for enhanced radiotherapy: Multi-site feasibility study. Endosc Int Open 2024; 12:E861-E867. [PMID: 38989255 PMCID: PMC11236477 DOI: 10.1055/a-2286-1995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/21/2024] [Indexed: 07/12/2024] Open
Abstract
Background and study aims The proximity of a pancreas head tumor to the duodenum often limits delivery of an ablative dose of radiation therapy. This study evaluated the feasibility and safety of using an injectable polyethylene glycol (PEG) hydrogel between the head of the pancreas and duodenum. Patients and methods In a multi-site feasibility cohort study of patients with localized pancreatic cancer, PEG hydrogel was injected under endoscopic ultrasound guidance to temporarily position the duodenum away from the pancreas. Procedure characteristics were recorded, including hydrogel volume and space created. Patients were monitored for adverse events (AEs) and radiotherapy toxicity. Results In all six intent-to-treat patients (four with borderline resectable, two with locally advanced disease), the ability to place and visualize PEG hydrogel and create space between the duodenum and the head of the pancreas was successful. There were no procedure-related AEs resulting in radiotherapy delay. There were no device-related AEs and no reports of pancreatitis. Conclusions PEG hydrogel was successfully placed, created space between the duodenum and the head of the pancreas, and was not associated with major toxicity. Enhancing radiotherapy for pancreatic cancer by using PEG hydrogel to create peri-duodenal space could have beneficial implications for treatment and warrants more exploration.
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Affiliation(s)
- Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, United States
| | - Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, United States
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, United States
| | - Brenna Casey
- Interventional Gastroenterology, Massachusetts General Hospital Harvard Medical School, Boston, United States
| | - Kumar Krishnan
- Gastroenterology, Massachusetts General Hospital, Boston, United States
| | - Eugene J Koay
- Department of GI Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, United States
| | - Theodore S Hong
- Radiation Oncology, Massachusetts General Hospital, Boston, United States
| | - Joseph M Herman
- Department of Radiation Medicine, Northwell, New Hyde Park, United States
| | | | - Eun Ji Shin
- Internal Medicine, Johns Hopkins Medicine, Baltimore, United States
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Narang AK, Hong TS, Ding K, Herman J, Meyer J, Thompson E, Bhutani MS, Krishnan K, Casey B, Shin EJ, Koay EJ. A Multi-Institutional Safety and Feasibility Study Exploring the Use of Hydrogel to Create Spatial Separation between the Pancreas and Duodenum in Patients with Pancreatic Cancer. Pract Radiat Oncol 2024; 14:e276-e282. [PMID: 38043645 DOI: 10.1016/j.prro.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE The administration of dose-escalated radiation for pancreatic adenocarcinoma remains challenging because of the proximity of dose-limiting stomach and bowel, particularly the duodenum for pancreatic head tumors. We explore whether endoscopic injection of a temporary, absorbable hydrogel into the pancreatico-duodenal (PD) groove is safe and feasible for the purpose of increasing spatial separation between pancreatic head tumors and the duodenum. METHODS AND MATERIALS Six patients with localized pancreatic adenocarcinoma underwent endoscopic injection of hydrogel into the PD groove. Safety was assessed based on the incidence of procedure-related adverse events resulting in a delay of radiation therapy initiation. Feasibility was defined as the ability to create spatial separation between the pancreas and duodenum, as assessed on simulation CT. RESULTS All 6 patients were able to undergo endoscopic injection of hydrogel into the PD groove. No device-related events were experienced at any point in follow-up. Presence of hydrogel in the PD groove was apparent on simulation CT in all 6 patients. Mean space created by the hydrogel was 7.7 mm +/- 2.4 mm. In 3 patients who underwent Whipple resection, presence of hydrogel in the PD groove was pathologically confirmed with no evidence of damage to the duodenum. CONCLUSIONS Endoscopic injection of hydrogel into the PD groove is safe and feasible. Characterization of the dosimetric benefit that this technique may offer in the setting of dose-escalated radiation should also be pursued, as should the ability of such dosimetric benefit to translate into clinically improved tumor control.
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Affiliation(s)
- Amol Kumar Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital Harvard Medical School, Boston, Massachusetts
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Joseph Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, New York
| | - Jeffrey Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth Thompson
- Department of Pathology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kumar Krishnan
- Division of Gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Brenna Casey
- Division of Gastroenterology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
| | - Eun Ji Shin
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eugene J Koay
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Grimbergen G, Eijkelenkamp H, Snoeren LM, Bahij R, Bernchou U, van der Bijl E, Heerkens HD, Binda S, Ng SS, Bouchart C, Paquier Z, Brown K, Khor R, Chuter R, Freear L, Dunlop A, Mitchell RA, Erickson BA, Hall WA, Godoy Scripes P, Tyagi N, de Leon J, Tran C, Oh S, Renz P, Shessel A, Taylor E, Intven MP, Meijer GJ. Treatment planning for MR-guided SBRT of pancreatic tumors on a 1.5 T MR-Linac: A global consensus protocol. Clin Transl Radiat Oncol 2024; 47:100797. [PMID: 38831754 PMCID: PMC11145226 DOI: 10.1016/j.ctro.2024.100797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/17/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024] Open
Abstract
Background and purpose Treatment planning for MR-guided stereotactic body radiotherapy (SBRT) for pancreatic tumors can be challenging, leading to a wide variation of protocols and practices. This study aimed to harmonize treatment planning by developing a consensus planning protocol for MR-guided pancreas SBRT on a 1.5 T MR-Linac. Materials and methods A consortium was founded of thirteen centers that treat pancreatic tumors on a 1.5 T MR-Linac. A phased planning exercise was conducted in which centers iteratively created treatment plans for two cases of pancreatic cancer. Each phase was followed by a meeting where the instructions for the next phase were determined. After three phases, a consensus protocol was reached. Results In the benchmarking phase (phase I), substantial variation between the SBRT protocols became apparent (for example, the gross tumor volume (GTV) D99% ranged between 36.8 - 53.7 Gy for case 1, 22.6 - 35.5 Gy for case 2). The next phase involved planning according to the same basic dosimetric objectives, constraints, and planning margins (phase II), which led to a large degree of harmonization (GTV D99% range: 47.9-53.6 Gy for case 1, 33.9-36.6 Gy for case 2). In phase III, the final consensus protocol was formulated in a treatment planning system template and again used for treatment planning. This not only resulted in further dosimetric harmonization (GTV D99% range: 48.2-50.9 Gy for case 1, 33.5-36.0 Gy for case 2) but also in less variation of estimated treatment delivery times. Conclusion A global consensus protocol has been developed for treatment planning for MR-guided pancreatic SBRT on a 1.5 T MR-Linac. Aside from harmonizing the large variation in the current clinical practice, this protocol can provide a starting point for centers that are planning to treat pancreatic tumors on MR-Linac systems.
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Affiliation(s)
- Guus Grimbergen
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Hidde Eijkelenkamp
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Louk M.W. Snoeren
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Rana Bahij
- Department of Oncology, Odense University Hospital, Denmark
| | - Uffe Bernchou
- Department of Oncology, Odense University Hospital, Denmark
- Department of Clinical Research, University of Southern Denmark, Denmark
| | - Erik van der Bijl
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - Hanne D. Heerkens
- Department of Radiation Oncology, Radboudumc, Nijmegen, The Netherlands
| | - Shawn Binda
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sylvia S.W. Ng
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Christelle Bouchart
- Department of Radiation Oncology, HUB Institut Jules Bordet, Brussels, Belgium
| | - Zelda Paquier
- Department of Radiation Oncology, HUB Institut Jules Bordet, Brussels, Belgium
| | - Kerryn Brown
- Radiation Oncology, ONJ Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Richard Khor
- Radiation Oncology, ONJ Centre, Austin Health, Heidelberg, Victoria, Australia
| | | | | | - Alex Dunlop
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Robert Adam Mitchell
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Beth A. Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paola Godoy Scripes
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Charles Tran
- GenesisCare, Darlinghurst, New South Wales, Australia
| | - Seungjong Oh
- Division of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Paul Renz
- Division of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Andrea Shessel
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Edward Taylor
- Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada
| | - Martijn P.W. Intven
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - Gert J. Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
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Shi C, De B, Tran Cao HS, Liu S, Florez MA, Kouzy R, Grippin AJ, Katz MHG, Tzeng CD, Ikoma N, Kim MP, Lee S, Willis J, Noticewala SS, Minsky BD, Smith GL, Holliday EB, Taniguchi CM, Koong AC, Das P, Ludmir EB, Koay EJ. Escalated-dose radiotherapy for unresected locally advanced pancreatic cancer: Patterns of care and survival in the United States. Cancer Med 2024; 13:e7434. [PMID: 38923407 PMCID: PMC11200087 DOI: 10.1002/cam4.7434] [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: 10/12/2023] [Revised: 05/30/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION With locally advanced pancreatic cancer (LAPC), uncontrolled local tumor growth frequently leads to mortality. Advancements in radiotherapy (RT) techniques have enabled conformal delivery of escalated-dose RT (EDR), which may have potential local control and overall survival (OS) benefits based on retrospective and early prospective studies. With evidence for EDR emerging, we characterized the adoption of EDR across the United States and its associated outcomes. METHODS We searched the National Cancer Database for nonsurgically managed LAPC patients diagnosed between 2004 and 2019. Pancreas-directed RT with biologically effective doses (BED10) ≥39 and ≤70 Gy was labeled conventional-dose RT (CDR), and BED10 >70 and ≤132 Gy was labeled EDR. We identified associations of EDR and OS using logistic and Cox regressions, respectively. RESULTS Among the definitive therapy subset (n = 54,115) of the entire study cohort (n = 91,493), the most common treatments were chemotherapy alone (69%), chemotherapy and radiation (29%), and RT alone (2%). For the radiation therapy subset (n = 16,978), use of pancreas-directed RT remained between 13% and 17% over the study period (ptrend > 0.999). Using multivariable logistic regression, treatment at an academic/research facility (adjusted odds ratio [aOR] 1.46, p < 0.001) and treatment between 2016 and 2019 (aOR 2.54, p < 0.001) were associated with greater receipt of EDR, whereas use of chemotherapy (aOR 0.60, p < 0.001) was associated with less receipt. Median OS estimates for EDR and CDR were 14.5 months and 13.0 months (p < 0.0001), respectively. For radiation therapy subset patients with available survival data (n = 13,579), multivariable Cox regression correlated EDR (adjusted hazard ratio 0.85, 95% confidence interval 0.80-0.91; p < 0.001) with longer OS versus CDR. DISCUSSION AND CONCLUSIONS Utilization of EDR has increased since 2016, but overall utilization of RT for LAPC has remained at less than one in five patients for almost two decades. These real-world results additionally provide an estimate of effect size of EDR for future prospective trials.
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Affiliation(s)
- Christopher Shi
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Brian De
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Hop S. Tran Cao
- Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Suyu Liu
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Marcus A. Florez
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ramez Kouzy
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Adam J. Grippin
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Matthew H. G. Katz
- Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ching‐Wei D. Tzeng
- Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Naruhiko Ikoma
- Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Michael P. Kim
- Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Sunyoung Lee
- Department of Gastrointestinal Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Jason Willis
- Department of Gastrointestinal Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Sonal S. Noticewala
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Bruce D. Minsky
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Grace L. Smith
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Emma B. Holliday
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Cullen M. Taniguchi
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Albert C. Koong
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Prajnan Das
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ethan B. Ludmir
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Eugene J. Koay
- Department of Gastrointestinal Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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Hoffe SE, Aguilera TA, Parikh PJ, Ghaly MM, Herman JM, Caster JM, Kim DW, Costello J, Malafa MP, Moser EC, Kennedy EP, Terry K, Kurman M. Stereotactic body radiotherapy plus rucosopasem in locally advanced or borderline resectable pancreatic cancer: GRECO-2 phase II study design. Future Oncol 2024; 20:437-446. [PMID: 38264869 PMCID: PMC10988540 DOI: 10.2217/fon-2022-1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/02/2023] [Indexed: 01/25/2024] Open
Abstract
Ablative doses of stereotactic body radiotherapy (SBRT) may improve pancreatic cancer outcomes but may carry greater potential for gastrointestinal toxicity. Rucosopasem, an investigational selective dismutase mimetic that converts superoxide to hydrogen peroxide, can potentially increase tumor control of SBRT without compromising safety. GRECO-2 is a phase II, multicenter, randomized, double-blind, placebo-controlled trial of rucosopasem in combination with SBRT in locally advanced or borderline resectable pancreatic cancer. Patients will be randomized to rucosopasem 100 mg or placebo via intravenous infusion over 15 min, before each SBRT fraction (5 × 10 Gy). The primary end point is overall survival. Secondary end points include progression-free survival, locoregional control, time to metastasis, surgical resection rate, best overall response, in-field local response and acute and long-term toxicity.
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Affiliation(s)
- Sarah E Hoffe
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Maged M Ghaly
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Herman
- Northwell Health Cancer Institute, New Hyde Park, NY 11040, USA
| | - Joseph M Caster
- Universty of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA
| | - Dae Won Kim
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - James Costello
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Mokenge P Malafa
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | | | | | - Kara Terry
- Galera Therapeutics, Inc., Malvern, PA 19355, USA
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6
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Shouman MA, Fuchs F, Walter F, Corradini S, Westphalen CB, Vornhülz M, Beyer G, Andrade D, Belka C, Niyazi M, Rogowski P. Stereotactic body radiotherapy for pancreatic cancer - A systematic review of prospective data. Clin Transl Radiat Oncol 2024; 45:100738. [PMID: 38370495 PMCID: PMC10873666 DOI: 10.1016/j.ctro.2024.100738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/05/2024] [Accepted: 01/26/2024] [Indexed: 02/20/2024] Open
Abstract
Purpose This systematic review aims to comprehensively summarize the current prospective evidence regarding Stereotactic Body Radiotherapy (SBRT) in various clinical contexts for pancreatic cancer including its use as neoadjuvant therapy for borderline resectable pancreatic cancer (BRPC), induction therapy for locally advanced pancreatic cancer (LAPC), salvage therapy for isolated local recurrence (ILR), adjuvant therapy after radical resection, and as a palliative treatment. Special attention is given to the application of magnetic resonance-guided radiotherapy (MRgRT). Methods Following PRISMA guidelines, a systematic review of the Medline database via PubMed was conducted focusing on prospective studies published within the past decade. Data were extracted concerning study characteristics, outcome measures, toxicity profiles, SBRT dosage and fractionation regimens, as well as additional systemic therapies. Results and conclusion 31 studies with in total 1,571 patients were included in this review encompassing 14 studies for LAPC, 9 for neoadjuvant treatment, 2 for adjuvant treatment, 2 for ILR, with an additional 4 studies evaluating MRgRT. In LAPC, SBRT demonstrates encouraging results, characterized by favorable local control rates. Several studies even report conversion to resectable disease with substantial resection rates reaching 39%. The adoption of MRgRT may provide a solution to the challenge to deliver ablative doses while minimizing severe toxicities. In BRPC, select prospective studies combining preoperative ablative-dose SBRT with modern induction systemic therapies have achieved remarkable resection rates of up to 80%. MRgRT also holds potential in this context. Adjuvant SBRT does not appear to confer relevant advantages over chemotherapy. While prospective data for SBRT in ILR and for palliative pain relief are limited, they corroborate positive findings from retrospective studies.
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Affiliation(s)
- Mohamed A Shouman
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Frederik Fuchs
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
| | - C Benedikt Westphalen
- Department of Medicine III and Comprehensive Cancer Center (CCC Munich LMU), University Hospital LMU, Munich, Germany
| | - Marlies Vornhülz
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Georg Beyer
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- Department of Internal Medicine II, LMU University Hospital, Munich, Germany
| | - Dorian Andrade
- Department of General, Visceral, and Transplant Surgery, University Hospital LMU, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Bavarian Cancer Research Center (BZKF), Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
- Department of Radiation Oncology, University Hospital Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), Partner Site Tübingen, Germany
| | - Paul Rogowski
- Department of Radiation Oncology, University Hospital LMU, Munich, Germany
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7
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Daamen LA, Parikh PJ, Hall WA. The Use of MR-Guided Radiation Therapy for Pancreatic Cancer. Semin Radiat Oncol 2024; 34:23-35. [PMID: 38105090 DOI: 10.1016/j.semradonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
The introduction of online adaptive magnetic resonance (MR)-guided radiation therapy (RT) has enabled safe treatment of pancreatic cancer with ablative doses. The aim of this review is to provide a comprehensive overview of the current literature on the use and clinical outcomes of MR-guided RT for treatment of pancreatic cancer. Relevant outcomes included toxicity, tumor response, survival and quality of life. The results of these studies support further investigation of the effectiveness of ablative MR-guided SBRT as a low-toxic, minimally-invasive therapy for localized pancreatic cancer in prospective clinical trials.
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Affiliation(s)
- Lois A Daamen
- Imaging & Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Parag J Parikh
- Department of Radiation Oncology, Henry Ford Medical Center, Henry Ford Health System, Detroit, MI
| | - William A Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI.
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8
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Kisivan K, Farkas A, Kovacs P, Glavak C, Lukacs G, Mahr K, Szabo Z, Csima MP, Gulyban A, Toth Z, Kaposztas Z, Lakosi F. Pancreatic SABR using peritumoral fiducials, triggered imaging and breath-hold. Pathol Oncol Res 2023; 29:1611456. [PMID: 38188611 PMCID: PMC10767757 DOI: 10.3389/pore.2023.1611456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/14/2023] [Indexed: 01/09/2024]
Abstract
Background: We aim to present our linear accelerator-based workflow for pancreatic stereotactic ablative radiotherapy (SABR) in order to address the following issues: intrafractional organ motion management, Cone Beam CT (CBCT) image quality, residual errors with dosimetric consequences, treatment time, and clinical results. Methods: Between 2016 and 2021, 14 patients with locally advanced pancreatic cancer were treated with induction chemotherapy and SABR using volumetric modulated arc therapy (VMAT). Internal target volume (ITV) concept (5), phase-gated (4), or breath hold (5) techniques were used. Treatment was verified by CBCT before and after irradiation, while tumor motion was monitored and controlled by kV triggered imaging and beam hold using peritumoral surgical clips. Beam interruptions and treatment time were recorded. The CBCT image quality was scored and supplemented by an agreement analysis (Krippendorff's-α) of breath-hold CBCT images to determine the position of OARs relative to the planning risk volumes (PRV). Residual errors and their dosimetry impact were also calculated. Progression free (PFS) and overall survival (OS) were assessed by the Kaplan-Meier analysis with acute and late toxicity reporting (CTCAEv4). Results: On average, beams were interrupted once (range: 0-3) per treatment session on triggered imaging. The total median treatment time was 16.7 ± 10.8 min, significantly less for breath-hold vs. phase-gated sessions (18.8 ± 6.2 vs. 26.5 ± 13.4, p < 0.001). The best image quality was achieved by breath hold CBCT. The Krippendorff's-α test showed a strong agreement among five radiation therapists (mean K-α value: 0.8 (97.5%). The mean residual errors were <0.2 cm in each direction resulting in an average difference of <2% in dosimetry for OAR and target volume. Two patients received offline adaptation. The median OS/PFS after induction chemotherapy and SABR was 20/12 months and 15/8 months. No Gr. ≥2 acute/late RT-related toxicity was noted. Conclusion: Linear accelerator based pancreatic SABR with the combination of CBCT and triggered imaging + beam hold is feasible. Peritumoral fiducials improve utility while breath-hold CBCT provides the best image quality at a reasonable treatment time with offline adaptation possibilities. In well-selected cases, it can be an effective alternative in clinics where CBCT/MRI-guided online adaptive workflow is not available.
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Affiliation(s)
- Katalin Kisivan
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Andrea Farkas
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Peter Kovacs
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Csaba Glavak
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Gabor Lukacs
- Department of Medical Oncology, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Karoly Mahr
- Department of Medical Oncology, Zala County Szent Raphael Hospital, Zalaegerszeg, Hungary
| | - Zsolt Szabo
- Department of Medical Oncology, Zala County Szent Raphael Hospital, Zalaegerszeg, Hungary
| | - Melinda Petone Csima
- Institute of Education, Hungarian University of Agricultural and Life Sciences, Gödöllő, Hungary
- Faculty of Health Sciences, University of Pecs, Pecs, Hungary
| | - Akos Gulyban
- Department of Medical Physics, Institut Jules Bordet, Brussels, Belgium
- Radiophysics and MRI Physics Laboratory, Université Libre De Bruxelles (ULB), Brussels, Belgium
| | - Zoltan Toth
- Medicopus Nonprofit Ltd., Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
- PET Center, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Zsolt Kaposztas
- Department of Surgery, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
| | - Ferenc Lakosi
- Department of Radiotherapy, Somogy County Kaposi Mór Teaching Hospital, Kaposvár, Hungary
- Faculty of Health Sciences, University of Pecs, Pecs, Hungary
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Taniguchi CM, Frakes JM, Aguilera TA, Palta M, Czito B, Bhutani MS, Colbert LE, Abi Jaoude J, Bernard V, Pant S, Tzeng CWD, Kim DW, Malafa M, Costello J, Mathew G, Rebueno N, Koay EJ, Das P, Ludmir EB, Katz MHG, Wolff RA, Beddar S, Sawakuchi GO, Moningi S, Slack Tidwell RS, Yuan Y, Thall PF, Beardsley RA, Holmlund J, Herman JM, Hoffe SE. Stereotactic body radiotherapy with or without selective dismutase mimetic in pancreatic adenocarcinoma: an adaptive, randomised, double-blind, placebo-controlled, phase 1b/2 trial. Lancet Oncol 2023; 24:1387-1398. [PMID: 38039992 DOI: 10.1016/s1470-2045(23)00478-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) has the potential to ablate localised pancreatic ductal adenocarcinoma. Selective dismutase mimetics sensitise tumours while reducing normal tissue toxicity. This trial was designed to establish the efficacy and toxicity afforded by the selective dismutase mimetic avasopasem manganese when combined with ablative SBRT for localised pancreatic ductal adenocarcinoma. METHODS In this adaptive, randomised, double-blind, placebo-controlled, phase 1b/2 trial, patients aged 18 years or older with borderline resectable or locally advanced pancreatic cancer who had received at least 3 months of chemotherapy and had an Eastern Cooperative Oncology Group performance status of 0-2 were enrolled at six academic sites in the USA. Eligible patients were randomly assigned (1:1), with block randomisation (block sizes of 6-12) with a maximum of 24 patients per group, to receive daily avasopasem (90 mg) or placebo intravenously directly before (ie, within 180 min) SBRT (50, 55, or 60 Gy in five fractions, adaptively assigned in real time by Bayesian estimates of 90-day safety and efficacy). Patients and physicians were masked to treatment group allocation, but not to SBRT dose. The primary objective was to find the optimal dose of SBRT with avasopasem or placebo as determined by the late onset EffTox method. All analyses were done on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, NCT03340974, and is complete. FINDINGS Between Jan 25, 2018, and April 29, 2020, 47 patients were screened, of whom 42 were enrolled (median age was 71 years [IQR 63-75], 23 [55%] were male, 19 [45%] were female, 37 [88%] were White, three [7%] were Black, and one [2%] each were unknown or other races) and randomly assigned to avasopasem (n=24) or placebo (n=18); the placebo group was terminated early after failing to meet prespecified efficacy parameters. At data cutoff (June 28, 2021), the avasopasem group satisfied boundaries for both efficacy and toxicity. Late onset EffTox efficacy response was observed in 16 (89%) of 18 patients at 50 Gy and six (100%) of six patients at 55 Gy in the avasopasem group, and was observed in three (50%) of six patients at 50 Gy and nine (75%) of 12 patients at 55 Gy in the placebo group, and the Bayesian model recommended 50 Gy or 55 Gy in five fractions with avasopasem for further study. Serious adverse events of any cause were reported in three (17%) of 18 patients in the placebo group and six (25%) of 24 in the avasopasem group. In the placebo group, grade 3 adverse events within 90 days of SBRT were abdominal pain, acute cholangitis, pyrexia, increased blood lactic acid, and increased lipase (one [6%] each); no grade 4 events occurred. In the avasopasem group, grade 3-4 adverse events within 90 days of SBRT were acute kidney injury, increased blood alkaline phosphatase, haematoma, colitis, gastric obstruction, lung infection, abdominal abscess, post-surgical atrial fibrillation, and pneumonia leading to respiratory failure (one [4%] each).There were no treatment-related deaths but one late death in the avasopasem group due to sepsis in the setting of duodenal obstruction after off-study treatment was reported as potentially related to SBRT. INTERPRETATION SBRT that uses 50 or 55 Gy in five fractions can be considered for patients with localised pancreatic ductal adenocarcinoma. The addition of avasopasem might further enhance disease outcomes. A larger phase 2 trial (GRECO-2, NCT04698915) is underway to validate these results. FUNDING Galera Therapeutics.
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Affiliation(s)
- Cullen M Taniguchi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica M Frakes
- Department of Radiation Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Todd A Aguilera
- Department of Radiation Oncology, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Manisha Palta
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, USA
| | - Brian Czito
- Department of Radiation Oncology, Duke Cancer Institute, Durham, NC, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lauren E Colbert
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Abi Jaoude
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vincent Bernard
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shubham Pant
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dae Won Kim
- Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - James Costello
- Department of Diagnostic Imaging and Interventional Radiology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geena Mathew
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neal Rebueno
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prajnan Das
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sam Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel O Sawakuchi
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shalini Moningi
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca S Slack Tidwell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ying Yuan
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Joseph M Herman
- Department of Radiation Oncology, Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, Hempstead, NY, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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Luo Y. The characteristic of stem-related genes with pancreatic carcinoma cell after irradiation. Heliyon 2023; 9:e17074. [PMID: 37484310 PMCID: PMC10361223 DOI: 10.1016/j.heliyon.2023.e17074] [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: 10/11/2022] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose To investigate stem-related differentially expressed genes (DEGs) and their potential mechanism in pancreatic cancer cells (MIAPaCa-2) exposed to x-ray and proton radiation, as well as how these factors affected the prognosis of patients with pancreatic adenocarcinoma (PADC). Methods The stem-related DEGs were screened using the online tool Stemchecker after protons and x-rays were used to irradiate MIAPaCa-2 cells. Analysis was done on the probable processes and prognostic significance of the DEGs in PAC patients. Results Four datasets containing 401 DEGs were filtered, and the stem-related DEGs for each irradiation type indicated a variety of radiobiological characteristics. In pancreatic cancer cells, a number of stem-related DEGs may serve as biomarkers of radiation effects. Patients with pancreatic cancer demonstrated predictive significance for GRB7, B2M, and PMAIP1. Conclusions MIAPaCa-2 cells exposed to x-rays and protons repeatedly displayed heterogeneous expression of stem-related DEGs involved in complex radiosensitivity, radio-resistance, and radio-induced mortality pathways. GRB7 and B2M were considered potential radiation sensitivity indicators for pancreatic cancer.
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11
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Wu TC, Yoon SM, Cao M, Raldow AC, Xiang M. Identifying predictors of on-table adaptation for pancreas stereotactic body radiotherapy (SBRT). Clin Transl Radiat Oncol 2023; 40:100603. [PMID: 36896266 PMCID: PMC9989520 DOI: 10.1016/j.ctro.2023.100603] [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: 11/30/2022] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023] Open
Abstract
Purpose To identify any clinical or dosimetric parameters that predict which individuals may benefit from on-table adaptation during pancreas stereotactic body radiotherapy (SBRT) with MRI-guided radiotherapy. Methods and materials This was a retrospective study of patients undergoing MRI-guided SBRT from 2016 to 2022. Pre-treatment clinical variables and dosimetric parameters on the patient's simulation scan were recorded for each SBRT course, and their ability to predict for on-table adaptation was analyzed using ordinal logistic regression. The outcome measure was number of fractions adapted. Results Sixty-three SBRT courses consisting of 315 fractions were analyzed. Median prescription dose was 40 Gy in five fractions (range, 33-50 Gy); 52% and 48% of courses were prescribed ≤40 Gy and >40 Gy, respectively. The median minimum dose delivered to 95% (D95) of the gross tumor volume (GTV) and planning target volume (PTV) was 40.1 Gy and 37.0 Gy, respectively. Median number of fractions adapted per course was three, with 58% (183 out of 315) total fractions adapted. On univariable analysis, the prescription dose (>40 Gy vs ≤40 Gy), GTV volume, stomach V20 and V25, duodenum V20 and dose maximum, large bowel V33 and V35, GTV dose minimum, PTV dose minimum, and gradient index were significant determinants for adaptation (all p < 0.05). On multivariable analysis, only the prescription dose was significant (adjusted odds ratio 19.7, p = 0.005), but did not remain significant after multiple test correction (p = 0.08). Conclusions The likelihood of needing on-table adaptation could not be reliably predicted a priori using pre-treatment clinical characteristics, dosimetry to nearby organs at risk, or other dosimetric parameters based on the patient's anatomy at the time of simulation, suggesting the critical importance of day-to-day variations in anatomy and increasing access to adaptive technology for pancreas SBRT. A higher (ablative) prescription dose was associated with increased use of adaptation.
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Affiliation(s)
- Trudy C Wu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Stephanie M Yoon
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Minsong Cao
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Ann C Raldow
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael Xiang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA, USA
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12
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Lee SL, Bassetti MF, Rusthoven CG. The Role of Stereotactic Body Radiation Therapy in the Management of Liver Metastases. Semin Radiat Oncol 2023; 33:181-192. [PMID: 36990635 DOI: 10.1016/j.semradonc.2022.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
The liver is a common site for metastatic spread for various primary tumor histologies. Stereotactic body radiation therapy (SBRT) is a non-invasive treatment technique with broad patient candidacy for the ablation of tumors in the liver and other organs. SBRT involves focused, high-dose radiation therapy delivered in one to several treatments, resulting in high rates of local control. Use of SBRT for ablation of oligometastatic disease has increased in recent years and emerging prospective data have demonstrated improvements in progression free and overall survival in some settings. When delivering SBRT to liver metastases, clinicians must balance the priorities of delivering ablative tumor dosing while respecting dose constraints to surrounding organs at risk (OARs). Motion management techniques are crucial for meeting dose constraints, ensuring low rates of toxicity, maintaining quality of life, and can allow for dose escalation. Advanced radiotherapy delivery approaches including proton therapy, robotic radiotherapy, and real-time MR-guided radiotherapy may further improve the accuracy of liver SBRT. In this article, we review the rationale for oligometastases ablation, the clinical outcomes with liver SBRT, tumor dose and OAR considerations, and evolving strategies to improve liver SBRT delivery.
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Affiliation(s)
- Sangjune Laurence Lee
- Division of Radiation Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, Canada.
| | - Michael F Bassetti
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Chad G Rusthoven
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
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13
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Hill CS, Herman JM. The Current Role of Radiation in Pancreatic Cancer and Future Directions. Clin Colorectal Cancer 2023; 22:12-23. [PMID: 36804206 DOI: 10.1016/j.clcc.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 12/15/2022] [Accepted: 01/24/2023] [Indexed: 02/01/2023]
Abstract
Survival outcomes for localized pancreatic adenocarcinoma remains poor. Multimodality therapeutic regimens are critical to maximizing survival outcomes for these patients, which includes the use of systemic therapy, surgery, and radiation. In this review, the evolution of radiation techniques are discussed with a focus on modern techniques such as intensity modulated radiation and stereotactic body radiation therapy. However, the current role of radiation within the most common clinical scenarios for pancreatic cancer in the neoadjuvant, definitive, and adjuvant settings continues to be highly debated. The role of radiation in these settings is reviewed in the context of historical and modern clinical studies. In addition, emerging concepts including dose-escalated radiation, magnetic resonance-guided radiation therapy, and particle therapy are discussed to promote an understanding of how such concepts may change the role of radiation in the future.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology, Perlmutter Cancer Center, New York University Grossman School of Medicine, New York, NY.
| | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, New York, NY
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14
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Liu X, Tao Y, Yang B, Pang T, Yu L, Li W, Feng S, Liu R, Li J, Liu Z, Qiu J. A novel X-Ray and γ-Ray combination strategy for potential dose escalation in patients with locally advanced pancreatic cancer. Med Phys 2023; 50:1855-1864. [PMID: 36458937 DOI: 10.1002/mp.16142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Treatment of locally advanced pancreatic cancer (LAPC) has long been calling for advances in technology of radiotherapy. Patients who received radiotherapy still had high risks of local recurrence, while suffering from gastrointestinal side effects. Based on the inherent characteristics of the x-ray and γ-Ray radiation techniques, here we proposed and investigated an unexplored radiation therapy. PURPOSE To investigate the potential clinical benefit of a novel x-ray and γ-Ray combination radiation technique in patients with LAPC. METHODS Retrospective intensity-modulated radiotherapy (IMRT) treatment plans of 10 LAPC patients were randomly selected to compare with dual-modality plans. The prescribed dose to PGTV was 60.2 Gy. The PGTV dose was further escalated in dual-modality plan while maintaining clinically tolerable dose to organs at risk (OARs). Dosimetric comparisons were made and analyzed for three treatment plans (tomotherapy, standard dual-modality plan, escalated dual-modality plan) to assess the ability to increase dose to target volume while minimizing dose in adjacent OARs. Finally, radiobiological models were utilized for comparison. RESULTS All strategies resulted in dosimetrically acceptable plans. Dual-modality plans were present with similar conformity index (CI) and significantly lower gradient index (GI) compared with tomotherapy (3.64 ± 0.37 vs. 4.14 ± 0.61, p = 0.002; 3.64 ± 0.42 vs. 4.14 ± 0.61, p = 0.003). Dmean of PGTV (65.46 ± 3.13 vs. 61.56 ± 1.00, p = 0.009; 77.98 ± 5.86 vs. 61.56 ± 1.00, p < 0.001) and PCTV (55.04 ± 2.14 vs. 53.93 ± 1.67, p = 0.016; 58.24 ± 3.24 vs. 53.93 ± 1.67, p = 0.001) were significantly higher, while Dmean of the stomach was reduced in both dual-modality plans (17.98 ± 10.23 vs. 19.34 ± 9.75, p = 0.024; 17.62 ± 9.92 vs. 19.34 ± 9.75, p = 0.040). The lower V30Gy in the liver (4.83 ± 5.87 vs. 6.23 ± 6.68, p = 0.015; 4.90 ± 5.93 vs. 6.23 ± 6.68, p = 0.016) and lower V45Gy of the small intestine (3.35 ± 3.30 vs. 4.06 ± 3.87, p = 0.052) were found in dual-modality plans. Meanwhile, radiobiological models demonstrated higher probability of tumor control (29.27% ± 9.61% vs. 18.34% ± 4.70%, p < 0.001; 44.67% ± 18.16% vs. 18.34% ± 4.70%, p = 0.001) and lower probability of small intestine complication (2.16% ± 2.30% vs. 1.25% ± 2.72%, p = 0.048) in favor of dual-modality strategy. CONCLUSIONS A novel dual-modality strategy of x-ray and γ-Ray combination radiation appears reliable for target dose escalation and normal tissue dose reduction. This strategy might be beneficial for local tumor control and the protection of normal organs in patients with LAPC.
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Affiliation(s)
- Xia Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinjie Tao
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Yang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingtian Pang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lang Yu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenbo Li
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Siqi Feng
- Our United Corporation, Xi'an, Shaanxi, China
| | - Renqing Liu
- Our United Corporation, Xi'an, Shaanxi, China
| | - Jinsheng Li
- Our United Corporation, Xi'an, Shaanxi, China
| | - Zhikai Liu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Qiu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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McDonald BA, Zachiu C, Christodouleas J, Naser MA, Ruschin M, Sonke JJ, Thorwarth D, Létourneau D, Tyagi N, Tadic T, Yang J, Li XA, Bernchou U, Hyer DE, Snyder JE, Bubula-Rehm E, Fuller CD, Brock KK. Dose accumulation for MR-guided adaptive radiotherapy: From practical considerations to state-of-the-art clinical implementation. Front Oncol 2023; 12:1086258. [PMID: 36776378 PMCID: PMC9909539 DOI: 10.3389/fonc.2022.1086258] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 01/27/2023] Open
Abstract
MRI-linear accelerator (MR-linac) devices have been introduced into clinical practice in recent years and have enabled MR-guided adaptive radiation therapy (MRgART). However, by accounting for anatomical changes throughout radiation therapy (RT) and delivering different treatment plans at each fraction, adaptive radiation therapy (ART) highlights several challenges in terms of calculating the total delivered dose. Dose accumulation strategies-which typically involve deformable image registration between planning images, deformable dose mapping, and voxel-wise dose summation-can be employed for ART to estimate the delivered dose. In MRgART, plan adaptation on MRI instead of CT necessitates additional considerations in the dose accumulation process because MRI pixel values do not contain the quantitative information used for dose calculation. In this review, we discuss considerations for dose accumulation specific to MRgART and in relation to current MR-linac clinical workflows. We present a general dose accumulation framework for MRgART and discuss relevant quality assurance criteria. Finally, we highlight the clinical importance of dose accumulation in the ART era as well as the possible ways in which dose accumulation can transform clinical practice and improve our ability to deliver personalized RT.
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Affiliation(s)
- Brigid A. McDonald
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cornel Zachiu
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Mohamed A. Naser
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mark Ruschin
- Department of Radiation Oncology, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jan-Jakob Sonke
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Daniela Thorwarth
- Section for Biomedical Physics, Department of Radiation Oncology, University of Tuebingen, Tuebingen, Germany
| | - Daniel Létourneau
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Neelam Tyagi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY, United States
| | - Tony Tadic
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - X. Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Uffe Bernchou
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Daniel E. Hyer
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Jeffrey E. Snyder
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | | | - Clifton D. Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kristy K. Brock
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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16
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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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17
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Kumar S, Singh SK, Srivastava P, Suresh S, Rana B, Rana A. Interplay between MAP kinases and tumor microenvironment: Opportunity for immunotherapy in pancreatic cancer. Adv Cancer Res 2023. [PMID: 37268394 DOI: 10.1016/bs.acr.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Pancreatic Ductal Adenocarcinoma (PDAC), commonly called pancreatic cancer, is aggressive cancer usually detected at a late stage, limiting treatment options with modest clinical responses. It is projected that by 2030, PDAC will be the second most common cause of cancer-related mortality in the United States. Drug resistance in PDAC is common and significantly affects patients' overall survival (OS). Oncogenic KRAS mutations are nearly uniform in PDAC, affecting over 90% of patients. However, effective drugs directed to target prevalent KRAS mutants in pancreatic cancer are not in clinical practice. Accordingly, efforts are continued on identifying alternative druggable target(s) or approaches to improve patient outcomes with PDAC. In most PDAC cases, the KRAS mutations turn-on the RAF-MEK-MAPK pathways, leading to pancreatic tumorigenesis. The MAPK signaling cascade (MAP4K→MAP3K→MAP2K→MAPK) plays a central role in the pancreatic cancer tumor microenvironment (TME) and chemotherapy resistance. The immunosuppressive pancreatic cancer TME is another unfavorable factor affecting the therapeutic efficacy of chemotherapy and immunotherapy. The immune checkpoint proteins (ICPs), including CTLA-4, PD-1, PD-L1, and PD-L2, are critical players in T cell dysfunction and pancreatic tumor cell growth. Here, we review the activation of MAPKs, a molecular trait of KRAS mutations and their impact on pancreatic cancer TME, chemoresistance, and expression of ICPs that could influence the clinical outcomes in PDAC patients. Therefore, understanding the interplay between MAPK pathways and TME could help to design rational therapy combining immunotherapy and MAPK inhibitors for pancreatic cancer treatment.
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Inflammatory Cytokines and Radiotherapy in Pancreatic Ductal Adenocarcinoma. Biomedicines 2022; 10:biomedicines10123215. [PMID: 36551971 PMCID: PMC9775272 DOI: 10.3390/biomedicines10123215] [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: 11/16/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a therapeutic challenge in clinical oncology. Surgery is the only potentially curative treatment. However, the majority of PDAC patients present with locally advanced/unresectable or metastatic disease, where palliative multiagent chemotherapy is the first-line treatment with the therapeutic intent to delay progression and prolong survival. For locally advanced/unresectable pancreatic cancer patients who are treated with chemotherapy, consolidative radiotherapy in the form concurrent chemoradiation or stereotactic ablative radiotherapy improves locoregional control and pain/symptom control. To improve clinical outcomes of PDAC patients, there is a dire need for discoveries that will shed more light on the pathophysiology of the disease and lead to the development of more efficacious treatment strategies. Inflammatory cytokines are known to play a role in mediating tumor progression, chemoresistance, and radioresistance in PDAC. A PubMed search on published articles related to radiotherapy, inflammatory cytokines, and pancreatic cancer patients in the English language was performed. This article primarily focuses on reviewing the clinical literature that examines the association of inflammatory cytokines with clinical outcomes and the effects of radiotherapy on inflammatory cytokines in PDAC patients.
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Advances in Radiation Oncology for Pancreatic Cancer: An Updated Review. Cancers (Basel) 2022; 14:cancers14235725. [PMID: 36497207 PMCID: PMC9736314 DOI: 10.3390/cancers14235725] [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: 10/05/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
This review aims to summarize the recent advances in radiation oncology for pancreatic cancer. A systematic search of the MEDLINE/PubMed database and Clinicaltrials.gov was performed, focusing on studies published within the last 10 years. Our search queried "locally advanced pancreatic cancer [AND] stereotactic body radiation therapy (SBRT) [OR] hypofractionation [OR] magnetic resonance guidance radiation therapy (MRgRT) [OR] proton" and "borderline resectable pancreatic cancer [AND] neoadjuvant radiation" and was limited only to prospective and retrospective studies and metanalyses. For locally advanced pancreatic cancers (LAPC), retrospective evidence supports the notion of radiation dose escalation to improve overall survival (OS). Novel methods for increasing the dose to high risk areas while avoiding dose to organs at risk (OARs) include SBRT or ablative hypofractionation using a simultaneous integrated boost (SIB) technique, MRgRT, or charged particle therapy. The use of molecularly targeted agents with radiation to improve radiosensitization has also shown promise in several prospective studies. For resectable and borderline resectable pancreatic cancers (RPC and BRPC), several randomized trials are currently underway to study whether current neoadjuvant regimens using radiation may be improved with the use of the multi-drug regimen FOLFIRINOX or immune checkpoint inhibitors.
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20
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Koay EJ, Zaid M, Aliru M, Bagereka P, Van Wieren A, Rodriguez MJ, Jacobson G, Wolff RA, Overman M, Varadhachary G, Pant S, Wang H, Tzeng CW, Ikoma N, Kim M, Lee JE, Katz MH, Tamm E, Bhosale P, Taniguchi CM, Holliday EB, Smith GL, Ludmir EB, Minsky BD, Crane CH, Koong AC, Das P, Wang X, Javle M, Krishnan S. Nab-Paclitaxel, Capecitabine, and Radiation Therapy After Induction Chemotherapy in Treating Patients With Locally Advanced and Borderline Resectable Pancreatic Cancer: Phase 1 Trial and Imaging-based Biomarker Validation. Int J Radiat Oncol Biol Phys 2022; 114:444-453. [PMID: 35863672 DOI: 10.1016/j.ijrobp.2022.06.089] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/13/2022] [Accepted: 06/24/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Effective consolidative chemoradiation (CRT) regimens are lacking. In this phase 1 trial, we evaluated the safety and efficacy of nab-paclitaxel, capecitabine, and radiation therapy after induction chemotherapy in patients with locally advanced and borderline-resectable pancreatic cancer (LAPC and BRPC). Also, we evaluated a computed tomography (CT)-based biomarker of response. METHODS AND MATERIALS Eligible patients had pathologically confirmed pancreatic ductal adenocarcinoma, underwent computed tomography-imaging, received a diagnosis of LAPC or BRPC, and received induction chemotherapy. Standard 3 + 3 study design was used, with 3 escalating nab-paclitaxel dose levels (50, 75, and 100 mg/m2) with concurrent capecitabine and RT in cohort sizes of 3 starting at the lowest dose. Dose limiting toxicity was defined as grade 3 or higher toxicity. Patients were restaged 4 to 6 weeks post-CRT completion, and surgical resection was offered to those with stable/responsive disease. We scored the tumor interface response (IR) postchemotherapy and post-CRT into type I (remained/became more defined) and type II (became less defined). Overall survival (OS) and progression-free survival (PFS) from time of CRT were estimated using Kaplan-Meier method. P ≤ .05 was considered significant. RESULTS Twenty-three patients started and finished on protocol (LAPC = 14, BRPC = 9). No grade 3 and 4 toxicities were reported in level 1 (n = 3) or level 2 (n = 3) initial groups. Two patients in the initial level 3 group developed dose limiting toxicity, establishing level 2 dose as the maximal tolerated dose. Level 2 group was expanded for additional 15 patients (for a total of 23 on trial), 5 of whom developed grade 3 toxicities. Seven patients underwent surgical resection. Median OS and PFS were 21.2 and 8.1 months, respectively. Type I IR was associated with better OS (P = .004) and PFS (P = .03) compared with type II IR. CONCLUSIONS We established the maximum tolerated dose for nab-paclitaxel in a consolidative CRT regimen for pancreatic ductal adenocarcinoma. Preliminary efficacy results warrant phase 2 trial evaluation. IR may be used for personalized treatment.
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Affiliation(s)
- Eugene J Koay
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas.
| | - Mohamed Zaid
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Maureen Aliru
- Graduate School of Biomedical Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Polycarpe Bagereka
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Arie Van Wieren
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Maria Jovie Rodriguez
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Galia Jacobson
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Robert A Wolff
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Overman
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gauri Varadhachary
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shubham Pant
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Huamin Wang
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew Hg Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric Tamm
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Priya Bhosale
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cullen M Taniguchi
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Emma B Holliday
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Ethan B Ludmir
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Albert C Koong
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of GI Radiation Oncology, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Milind Javle
- Department of GI Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
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21
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Hill CS, Rosati L, Wang H, Tsai HL, He J, Hacker-Prietz A, Laheru DA, Zheng L, Sehgal S, Bernard V, Le DT, Pawlik TM, Weiss MJ, Narang AK, Herman JM. Multiagent Chemotherapy and Stereotactic Body Radiation Therapy in Patients with Unresectable Pancreatic Adenocarcinoma: A Prospective Nonrandomized Controlled Trial. Pract Radiat Oncol 2022; 12:511-523. [PMID: 35306231 PMCID: PMC9516435 DOI: 10.1016/j.prro.2022.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/22/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE In a prospective multicenter study, gemcitabine monotherapy followed by stereotactic body radiation therapy (SBRT) was well tolerated with outcomes comparable to chemoradiation for locally advanced pancreatic cancer (LAPC). Recent trials have reported improved survival with multiagent chemotherapy (MA-CTX) alone. This prospective trial explored whether SBRT could be safely delivered after MA-CTX. Herein, we report the long-term outcomes of adding SBRT after MA-CTX in LAPC patients and evaluate whether genetic profiles of specimens obtained before SBRT influence outcomes. METHODS AND MATERIALS This prospective nonrandomized controlled phase 2 trial enrolled 44 LAPC and 4 locally recurrent patients after multidisciplinary evaluation between 2012 and 2015 at a high-volume pancreatic cancer center. For induction CTX, most received modified FOLFIRINOX (mFFX), or gemcitabine and nab-paclitaxel (GnP) followed by 5-fraction SBRT for all. During fiducial placement, biopsies were obtained with DNA extracted for targeted sequencing using the Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets platform. RESULTS Median induction CTX duration was ≥4 months, and 31 patients received mFFX (65%). Among 44 LAPC patients, 17 (39%) were surgically explored, and 12 of 16 (75%) achieved a R0 resection. Median overall survival (mOS) was 20.2 and 14.6 months from diagnosis and SBRT, respectively. One- and 2-year OS from SBRT was 58% and 28%. The mOS after resection was 28.6 and 22.4 months from diagnosis and SBRT, respectively. Median local progression-free survival was 23.9 and 15.8 months from diagnosis and SBRT, respectively. The mOS for pre-SBRT CA 19-9 ≤180 U/mL versus >180 was 23.1 and 11.3 months, respectively (hazard ratio, 0.53; P = .04). Only 1 patient (2.1%) had late grade ≥2 gastrointestinal toxic effects attributable to SBRT. Despite significant pretreatment with chemotherapy, 88% of tumor specimens were effectively sequenced; survival outcomes were not significantly associated with specific mutational patterns. Quality of life was prospectively collected pre- and post-SBRT with the EORTC QLQ-C30 and PAN26 questionnaires showing no significant change. CONCLUSIONS SBRT was safely administered with MA-CTX with minimal toxicity. A high proportion of LAPC patients underwent R0 resection with favorable survival outcomes.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lauren Rosati
- University of South Carolina School of Medicine, Columbia, South Carolina
| | - Hao Wang
- Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hua-Ling Tsai
- Division of Biostatistics and Bioinformatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amy Hacker-Prietz
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel A Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shuchi Sehgal
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Vincent Bernard
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Dung T Le
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M Pawlik
- Department of Surgery, Ohio State Comprehensive Cancer Center, Columbus, Ohio
| | - Matthew J Weiss
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Amol K Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success and Zucker School of Medicine, Hempstead, New York.
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22
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Burkoň P, Trna J, Slávik M, Němeček R, Kazda T, Pospíšil P, Dastych M, Eid M, Novotný I, Procházka T, Vrzal M. Stereotactic Body Radiotherapy (SBRT) of Pancreatic Cancer-A Critical Review and Practical Consideration. Biomedicines 2022; 10:biomedicines10102480. [PMID: 36289742 PMCID: PMC9599229 DOI: 10.3390/biomedicines10102480] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/18/2022] [Accepted: 09/30/2022] [Indexed: 11/23/2022] Open
Abstract
Pancreatic cancer is the third leading cause of cancer death in the developed world and is predicted to become the second by 2030. A cure may be achieved only with surgical resection of an early diagnosed disease. Surgery for more advanced disease is challenging and can be contraindicated for many reasons. Neoadjuvant therapy may improve the probability of achieving R0 resection. It consists of systemic treatment followed by radiation therapy applied concurrently or sequentially with cytostatics. A novel approach to irradiation, stereotactic body radiotherapy (SBRT), has the potential to improve treatment results. SBRT can deliver higher doses of radiation to the tumor in only a few treatment fractions. It has attracted significant interest for pancreatic cancer patients, as it is completed quickly, requires less time away from full-dose chemotherapy, and is well-tolerated than conventional radiotherapy. In this review, we aim to provide the reader with a basic overview of current evidence for SBRT indications in the treatment of pancreatic tumors. In the second part of the review, we focus on practical information with respect to SBRT treatment plan preparation the performance of such therapy. Finally, we discuss future directions related to the use of magnetic resonance linear accelerators.
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Affiliation(s)
- Petr Burkoň
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Jan Trna
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Marek Slávik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Correspondence: (J.T.); (M.S.)
| | - Radim Němeček
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Petr Pospíšil
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Milan Dastych
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Gastroenterology, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Michal Eid
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Jihlavska 340/20, 625 00 Brno, Czech Republic
| | - Ivo Novotný
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 53 Brno, Czech Republic
| | - Tomáš Procházka
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Kamenice 753/5, 625 00 Brno, Czech Republic
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Zluty Kopec 7, 656 57 Brno, Czech Republic
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23
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Schiff JP, Price AT, Stowe HB, Laugeman E, Chin RI, Hatscher C, Pryser E, Cai B, Hugo GD, Kim H, Badiyan SN, Robinson CG, Henke LE. Simulated computed tomography-guided stereotactic adaptive radiotherapy (CT-STAR) for the treatment of locally advanced pancreatic cancer. Radiother Oncol 2022; 175:144-151. [PMID: 36063981 DOI: 10.1016/j.radonc.2022.08.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE We conducted a prospective, in silico imaging clinical trial to evaluate the feasibility and potential dosimetric benefits of computed tomography-guided stereotactic adaptive radiotherapy (CT-STAR) for the treatment of locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Eight patients with LAPC received five additional CBCTs on the ETHOS system before or after their standard of care radiotherapy treatment. Initial plans were created based on their initial simulation anatomy (PI) and emulated adaptive plans were created based on their anatomy-of-the-day (PA). The prescription was 50 Gy/5 fractions. Plans were created under a strict isotoxicity approach, in which organ-at-risk (OAR) constraints were prioritized over planning target volume coverage. The PI was evaluated on the patient's anatomy-of-the-day, compared to the daily PA, and the superior plan was selected. Feasibility was defined as successful completion of the workflow in compliance with strict OAR constraints in ≥80% of fractions. RESULTS CT-STAR was feasible in silico for LAPC and improved OAR and/or target dosimetry in 100% of fractions. Use of the PI based on the patient's anatomy-of-the-day would have yielded a total of 94 OAR constraint violations and ≥1 hard constraint violation in 40/40 fractions. In contrast, 39/40 PA met all OAR constraints. In one fraction, the PA minimally exceeded the large bowel constraint, although dosimetrically improved compared to the PI. Total workflow time per fraction was 36.28 minutes (27.57-55.86). CONCLUSION CT-STAR for the treatment of LAPC cancer proved feasible and was dosimetrically superior to non-adapted CT-stereotactic body radiotherapy.
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Affiliation(s)
- Joshua P Schiff
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Eric Laugeman
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Re-I Chin
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Casey Hatscher
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Eleanor Pryser
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Bin Cai
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, 2280 Inwood Road, Dallas, TX 75390, USA.
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Hyun Kim
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Shahed N Badiyan
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Clifford G Robinson
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, 4921 Parkview Place, Campus Box 8224, St. Louis, MO 63110, USA.
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24
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Borakati A, Froghi F, Bhogal RH, Mavroeidis VK. Stereotactic radiotherapy for intrahepatic cholangiocarcinoma. World J Gastrointest Oncol 2022; 14:1478-1489. [PMID: 36160742 PMCID: PMC9412934 DOI: 10.4251/wjgo.v14.i8.1478] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/07/2022] [Accepted: 07/06/2022] [Indexed: 02/05/2023] Open
Abstract
Intrahepatic cholangiocarcinoma (iCCA) is an aggressive malignancy with an increasing incidence worldwide and poor prognosis, despite several advances and continuous efforts to develop effective treatments. Complete surgical resection is the mainstay of treatment and offers a potentially curative option, but is only possible in less than a third of patients, owing to advanced disease. Chemotherapy is a well-established treatment in the adjuvant and palliative setting, however, confers limited benefit. Conventional radiotherapy is challenging due to local toxicity. With recent advances in stereotactic ablative radiotherapy (SABR), it is now possible to focus ablative beams of radiotherapy precisely aimed at tumours to minimise damage to surrounding viscera. This review details the history, technical background and application of SABR to iCCA, with directions for future research suggested.
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Affiliation(s)
- Aditya Borakati
- Department of Surgery, The Royal London Hospital, Barts Health NHS Trust, London E1 1FR, United Kingdom
| | - Farid Froghi
- Department of HPB and Liver Transplantation Surgery, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, United Kingdom
| | - Ricky H Bhogal
- Department of Academic Surgery, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
| | - Vasileios K Mavroeidis
- Department of Academic Surgery, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
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25
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Zheng Y, Huang R, Zou W, Liu C, Niu H, Yue J. Comparing concurrent chemoradiotherapy,
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I seed implantation combined with chemotherapy, and chemotherapy alone efficacy in treating unresectable locally advanced pancreatic cancer. PRECISION RADIATION ONCOLOGY 2022. [DOI: 10.1002/pro6.1156] [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] Open
Affiliation(s)
- Yanfen Zheng
- Department of Graduate, Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan Shandong China
| | - Rui Huang
- Department of Graduate, Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan Shandong China
| | - Wenxue Zou
- Department of Graduate, Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan Shandong China
| | - Chao Liu
- Department of Radiation Oncology Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan Shandong China
| | - Hongxin Niu
- Department of Interventional Oncology Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan Shandong China
| | - Jinbo Yue
- Department of Radiation Oncology Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences Jinan Shandong China
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26
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Shewalkar B, Khan A, Yerlekar D, Patel J, Khadilkar H, Sakthivel R, Kataruka R. Dose-Escalated Intensity-Modulated Radiotherapy for the Management of Locally Advanced Cervical Cancer. Cureus 2022; 14:e25965. [PMID: 35855254 PMCID: PMC9285639 DOI: 10.7759/cureus.25965] [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] [Accepted: 06/15/2022] [Indexed: 11/05/2022] Open
Abstract
Objective In this study, we aimed to assess the response and toxicity related to dose escalation in external beam radiation therapy (EBRT) using intensity-modulated radiation therapy (IMRT) with weekly concurrent cisplatin followed by de-escalated brachytherapy (BT) in locally advanced carcinoma cervix of International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IIB-IIIC1. Materials and methods Fifty-two patients diagnosed with cervical cancer FIGO 2018 stage IIB-IIIC1 were treated with curative intent from November 2019 to October 2021. The dose of 50 Gy was prescribed for the primary tumor volume and elective pelvic nodal volume followed by a primary boost to a dose of 20 Gy. Gross lymph node (LN) of size >1 cm after EBRT completion received a sequential nodal boost of 10 Gy. All patients received concurrent cisplatin to a dose of 40 mg/m2 for a total of five to six weekly cycles. All patients received two fractions of BT to a dose of 6 Gy after EBRT completion. Radiation-induced acute toxicities were graded according to the Radiation Therapy Oncology Group (RTOG) criteria and hematologic toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE v4.0). Results A median follow-up of six months was available for the 40 eligible patients. All patients tolerated treatment with an acceptable toxicity profile. Grade III dermatitis, grade III gastrointestinal (GI) toxicity, and grade III genitourinary (GU) toxicity were seen in three (7.5%), six (17.5%), and three patients (7.5%) respectively. Grade I anemia was evident in all patients. At six months after EBRT completion, 37 patients (92.5%) had a complete response and only three patients (7.5%) had residual disease. Conclusion Based on our findings, patients with cervical cancer treated with dose-escalated IMRT have a satisfactory outcome with reasonably low levels of treatment-related acute GI and GU toxicities. The findings of the present study endorse the notion that the application of a high dose of external radiation to the pelvis by IMRT technique with image-guided delivery could be an acceptable alternative to the standard-dose management schedule.
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Affiliation(s)
- Balaji Shewalkar
- Radiation Oncology, Government Medical College and Cancer Hospital, Aurangabad, IND
| | - Asfiya Khan
- Radiation Oncology, Government Medical College and Cancer Hospital, Aurangabad, IND
| | - Dnyanda Yerlekar
- Radiation Oncology, Government Medical College and Cancer Hospital, Aurangabad, IND
| | - Jitendra Patel
- Radiation Oncology, Government Medical College and Cancer Hospital, Aurangabad, IND
| | - Hrishikesh Khadilkar
- Preventive Oncology, Government Medical College and Cancer Hospital, Aurangabad, IND
| | - Rajakumar Sakthivel
- Radiation Oncology, Government Medical College and Cancer Hospital, Aurangabad, IND
| | - Reeta Kataruka
- Pathology, Government Medical College and Cancer Hospital, Aurangabad, IND
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27
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Diez P, Hanna GG, Aitken KL, van As N, Carver A, Colaco RJ, Conibear J, Dunne EM, Eaton DJ, Franks KN, Good JS, Harrow S, Hatfield P, Hawkins MA, Jain S, McDonald F, Patel R, Rackley T, Sanghera P, Tree A, Murray L. UK 2022 Consensus on Normal Tissue Dose-Volume Constraints for Oligometastatic, Primary Lung and Hepatocellular Carcinoma Stereotactic Ablative Radiotherapy. Clin Oncol (R Coll Radiol) 2022; 34:288-300. [PMID: 35272913 DOI: 10.1016/j.clon.2022.02.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 12/25/2022]
Abstract
The use of stereotactic ablative radiotherapy (SABR) in the UK has expanded over the past decade, in part as the result of several UK clinical trials and a recent NHS England Commissioning through Evaluation programme. A UK SABR Consortium consensus for normal tissue constraints for SABR was published in 2017, based on the existing literature at the time. The published literature regarding SABR has increased in volume over the past 5 years and multiple UK centres are currently working to develop new SABR services. A review and update of the previous consensus is therefore appropriate and timely. It is hoped that this document will provide a useful resource to facilitate safe and consistent SABR practice.
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Affiliation(s)
- P Diez
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK
| | - G G Hanna
- Belfast Health and Social Care Trust, Belfast, UK; Queen's University Belfast, Belfast, UK
| | - K L Aitken
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; Institute of Cancer Research, London, UK
| | - N van As
- Institute of Cancer Research, London, UK; Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Chelsea, London, UK
| | - A Carver
- Department of Medical Physics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Medical Centre, Edgbaston, Birmingham, UK
| | - R J Colaco
- Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - J Conibear
- Radiotherapy Department, Barts Cancer Centre, London, UK
| | - E M Dunne
- Department of Clinical Oncology, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - D J Eaton
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK; Department of Medical Physics, Guys and St Thomas' NHS Foundation Trust, London, UK; School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - K N Franks
- Department of Clinical Oncology, Leeds Cancer Centre, St James's University Hospitals, Leeds, UK
| | - J S Good
- Department of Clinical Oncology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - S Harrow
- Department of Clinical Oncology, Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - P Hatfield
- Department of Clinical Oncology, Leeds Cancer Centre, St James's University Hospitals, Leeds, UK
| | - M A Hawkins
- Department of Medical Physics and Biomechanical Engineering, University College London, London, UK; Department of Clinical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Jain
- Belfast Health and Social Care Trust, Belfast, UK; Queen's University Belfast, Belfast, UK
| | - F McDonald
- Institute of Cancer Research, London, UK; Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Chelsea, London, UK
| | - R Patel
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK
| | - T Rackley
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK
| | - P Sanghera
- Department of Clinical Oncology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK
| | - A Tree
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK; Institute of Cancer Research, London, UK
| | - L Murray
- Department of Clinical Oncology, Leeds Cancer Centre, St James's University Hospitals, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK.
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28
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Simoni N, Rossi G, Cellini F, Vitolo V, Orlandi E, Valentini V, Mazzarotto R, Sverzellati N, D'Abbiero N. Ablative Radiotherapy (ART) for Locally Advanced Pancreatic Cancer (LAPC): Toward a New Paradigm? Life (Basel) 2022; 12:life12040465. [PMID: 35454956 PMCID: PMC9025325 DOI: 10.3390/life12040465] [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: 03/04/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022] Open
Abstract
Locally advanced pancreatic cancer (LAPC) represents a major urgency in oncology. Due to the massive involvement of the peripancreatic vessels, a curative-intent surgery is generally precluded. Historically, LAPC has been an indication for palliative systemic therapy. In recent years, with the introduction of intensive multi-agent chemotherapy regimens and aggressive surgical approaches, the survival of LAPC patients has significantly improved. In this complex and rapidly evolving scenario, the role of radiotherapy is still debated. The use of standard-dose conventional fractionated radiotherapy in LAPC has led to unsatisfactory oncological outcomes. However, technological advances in radiation therapy over recent years have definitively changed this paradigm. The use of ablative doses of radiotherapy, in association with image-guidance, respiratory organ-motion management, and adaptive protocols, has led to unprecedented results in terms of local control and survival. In this overview, principles, clinical applications, and current pitfalls of ablative radiotherapy (ART) as an emerging treatment option for LAPC are discussed.
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Affiliation(s)
- Nicola Simoni
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
| | - Gabriella Rossi
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy
| | - Francesco Cellini
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168 Roma, Italy
| | - Viviana Vitolo
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Ester Orlandi
- Radiation Oncology Clinical Department, National Center for Oncological Hadrontherapy (CNAO), 27100 Pavia, Italy
| | - Vincenzo Valentini
- Radioterapia Oncologica ed Ematologia, Dipartimento Universitario Diagnostica per Immagini, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
- Radioterapia Oncologica ed Ematologia, Dipartimento di Diagnostica per Immagini, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168 Roma, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy
| | - Nicola Sverzellati
- Division of Radiology, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
| | - Nunziata D'Abbiero
- Radiotherapy Unit, Azienda Ospedaliera Universitaria, 43126 Parma, Italy
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Shi Z, Yang J, Kong W, Qiu X, Lu C, Liu J, Liu B, Du J. Use of Nab-Paclitaxel Plus Gemcitabine Followed by Hypofractionated Tomotherapy With Simultaneous Integrated Boost in Patients With Locally Advanced Pancreatic Cancer. Front Oncol 2022; 12:782730. [PMID: 35299738 PMCID: PMC8922029 DOI: 10.3389/fonc.2022.782730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/31/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Purpose A phase 2 study LAPACT indicated nab-paclitaxel plus gemcitabine (AG) improved outcomes of patients with locally advanced pancreatic cancer (LAPC). Conventional radiotherapy failed to show benefit, indicating high dose to volume with high risk of recurrence is needed. The high dose can be delivered through hypofractionated tomotherapy with simultaneous integrated boost (SIB). However, there is a lack of such prospective trials and more data are needed to validate the role of AG plus hypofractionated tomotherapy with SIB in patients with LAPC. Materials and Methods Patients with LAPC receiving AG plus tomotherapy at the Nanjing Drum Tower Hospital between 2018 and 2021 were retrospectively analyzed. The treatment was scheduled as follows: nab-paclitaxel 125 mg/m2 plus gemcitabine 1,000 mg/m2 on days 1 and 8 every three weeks for at least two cycles, followed by hypofractionated tomotherapy with SIB (high dose field: 50 Gy/10 fractions, the remainder: 30 Gy/10 fractions). Then patients were given AG until intolerance or disease progression. Results Overall, 22 patients completing the chemoradiotherapy were included. The median follow-up was 15.2 months. After the chemoradiotherapy, 5 patients achieved a partial response (PR), 15 had a stable disease (SD), and another 2 patients were with progressive disease (PD). The median progression-free survival (PFS) and overall survival (OS) were 12.8 months (95% confidence interval [CI] 4.3-21.3 months) and 16.3 months (95% CI 10.9-21.6 months), respectively. The optimal carbohydrate antigen (CA) 19-9 response and chemotherapy cycles ≥6 were correlated with favorable PFS and OS. The most common recurrent pattern was peritoneal dissemination (22.7%) and the locoregional recurrence rate was relatively low (4.5%). Treatments were well-tolerated. The most common grade ≥3 adverse event was thrombocytopenia (13.6%). Conclusion This study demonstrated the feasibility of AG followed by hypofractionated tomotherapy with SIB in patients with LAPC. The hypofractionated tomotherapy with SIB was safe and showed high local control rate. Further study with a larger population to validate our data is underway.
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Affiliation(s)
- Zhan Shi
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Ju Yang
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Weiwei Kong
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Xin Qiu
- The Comprehensive Cancer Center of Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Changchang Lu
- The Comprehensive Cancer Center of Drum Tower Hospital, Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Juan Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Baorui Liu
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
| | - Juan Du
- The Comprehensive Cancer Centre of Drum Tower Hospital, Medical School of Nanjing University, Clinical Cancer Institute of Nanjing University, Nanjing, China
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30
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Ermongkonchai T, Khor R, Muralidharan V, Tebbutt N, Lim K, Kutaiba N, Ng SP. Stereotactic radiotherapy and the potential role of magnetic resonance-guided adaptive techniques for pancreatic cancer. World J Gastroenterol 2022; 28:745-754. [PMID: 35317275 PMCID: PMC8891728 DOI: 10.3748/wjg.v28.i7.745] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/11/2021] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer is a malignancy with one of the poorest prognoses amongst all cancers. Patients with unresectable tumours either receive palliative care or undergo various chemoradiotherapy regimens. Conventional techniques are often associated with acute gastrointestinal toxicities, as adjacent critical structures such as the duodenum ultimately limits delivered doses. Stereotactic body radiotherapy (SBRT) is an advanced radiation technique that delivers highly ablative radiation split into several fractions, with a steep dose fall-off outside target volumes.
AIM To discuss the latest data on SBRT and whether there is a role for magnetic resonance-guided techniques in multimodal management of locally advanced, unresectable pancreatic cancer.
METHODS We conducted a search on multiple large databases to collate the latest records on radiotherapy techniques used to treat pancreatic cancer. Out of 1229 total records retrieved from our search, 36 studies were included in this review.
RESULTS Studies indicate that SBRT is associated with improved clinical efficacy and toxicity profiles compared to conventional radiotherapy techniques. Further dose escalation to the tumour with SBRT is limited by the poor soft-tissue visualisation of computed tomography imaging during radiation planning and treatment delivery. Magnetic resonance-guided techniques have been introduced to improve imaging quality, enabling treatment plan adaptation and re-optimisation before delivering each fraction.
CONCLUSION Therefore, SBRT may lead to improved survival outcomes and safer toxicity profiles compared to conventional techniques, and the addition of magnetic resonance-guided techniques potentially allows dose escalation and conversion of unresectable tumours to operable cases.
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Affiliation(s)
- Tai Ermongkonchai
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Niall Tebbutt
- Department of Medical Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Kelvin Lim
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Numan Kutaiba
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
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31
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Feng Z, Hooshangnejad H, Shin EJ, Narang A, Lediju Bell MA, Ding K. The Feasibility of Haar Feature-Based Endoscopic Ultrasound Probe Tracking for Implanting Hydrogel Spacer in Radiation Therapy for Pancreatic Cancer. Front Oncol 2021; 11:759811. [PMID: 34804959 PMCID: PMC8599366 DOI: 10.3389/fonc.2021.759811] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/11/2021] [Indexed: 01/24/2023] Open
Abstract
Purpose We proposed a Haar feature-based method for tracking endoscopic ultrasound (EUS) probe in diagnostic computed tomography (CT) and Magnetic Resonance Imaging (MRI) scans for guiding hydrogel injection without external tracking hardware. This study aimed to assess the feasibility of implementing our method with phantom and patient images. Materials and Methods Our methods included the pre-simulation section and Haar features extraction steps. Firstly, the simulated EUS set was generated based on anatomic information of interpolated CT/MRI images. Secondly, the efficient Haar features were extracted from simulated EUS images to create a Haar feature dictionary. The relative EUS probe position was estimated by searching the best matched Haar feature vector of the dictionary with Haar feature vector of target EUS images. The utilization of this method was validated using EUS phantom and patient CT/MRI images. Results In the phantom experiment, we showed that our Haar feature-based EUS probe tracking method can find the best matched simulated EUS image from a simulated EUS dictionary which includes 123 simulated images. The errors of all four target points between the real EUS image and the best matched EUS images were within 1 mm. In the patient CT/MRI scans, the best matched simulated EUS image was selected by our method accurately, thereby confirming the probe location. However, when applying our method in MRI images, our method is not always robust due to the low image resolution. Conclusions Our Haar feature-based method is capable to find the best matched simulated EUS image from the dictionary. We demonstrated the feasibility of our method for tracking EUS probe without external tracking hardware, thereby guiding the hydrogel injection between the head of the pancreas and duodenum.
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Affiliation(s)
- Ziwei Feng
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, United States.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Hamed Hooshangnejad
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eun Ji Shin
- Department of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Muyinatu A Lediju Bell
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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32
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Iyengar P, Zhang-Velten E, Court L, Westover K, Yan Y, Lin MH, Xiong Z, Patel M, Rivera D, Chang J, Saunders M, Shivnani A, Lee A, Hughes R, Gerber D, Dowell J, Gao A, Heinzerling J, Li Y, Ahn C, Choy H, Timmerman R. Accelerated Hypofractionated Image-Guided vs Conventional Radiotherapy for Patients With Stage II/III Non-Small Cell Lung Cancer and Poor Performance Status: A Randomized Clinical Trial. JAMA Oncol 2021; 7:1497-1505. [PMID: 34383006 DOI: 10.1001/jamaoncol.2021.3186] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance A significant subset of patients with stage II/III non-small cell lung cancer (NSCLC) cannot receive standard concurrent chemoradiotherapy owing to the risk of toxic effects outweighing potential benefits. Without concurrent chemotherapy, however, the efficacy of conventional radiotherapy is reduced. Objective To determine whether hypofractionated image-guided radiotherapy (IGRT) would improve overall survival in patients with stage II/III NSCLC who could not receive concurrent chemoradiotherapy and therefore were traditionally relegated to receiving only conventionally fractionated radiotherapy (CFRT). Design, Setting, and Participants This nonblinded, phase 3 randomized clinical study enrolled 103 patients and analyzed 96 patients with stage II/III NSCLC and Zubrod performance status of at least 2, with greater than 10% weight loss in the previous 6 months, and/or who were ineligible for concurrent chemoradiotherapy after oncology consultation. Enrollment occurred at multiple US institutions. Patients were enrolled from November 13, 2012, to August 28, 2018, with a median follow-up of 8.7 (3.6-19.9) months. Data were analyzed from September 14, 2018, to April 11, 2021. Interventions Eligible patients were randomized to hypofractionated IGRT (60 Gy in 15 fractions) vs CFRT (60 Gy in 30 fractions). Main Outcomes and Measures The primary end point was 1-year overall survival. Results A total of 103 patients (96 of whom were analyzed [63 men (65.6%); mean (SD) age, 71.0 (10.2) years (range, 50-90 years)]) were randomized to hypofractionated IGRT (n = 50) or CFRT (n = 46) when a planned interim analysis suggested futility in reaching the primary end point, and the study was closed to further accrual. There was no statistically significant difference between the treatment groups for 1-year overall survival (37.7% [95% CI, 24.2%-51.0%] for hypofractionated IGRT vs 44.6% [95% CI, 29.9%-58.3%] for CFRT; P = .29). There were also no significant differences in median overall survival, progression-free survival, time to local failure, time to distant metastasis, and toxic effects of grade 3 or greater between the 2 treatment groups. Conclusions and Relevance This phase 3 randomized clinical trial found that hypofractionated IGRT (60 Gy in 15 fractions) was not superior to CFRT (60 Gy in 30 fractions) for patients with stage II/III NSCLC ineligible for concurrent chemoradiotherapy. Further studies are needed to verify equivalence between these radiotherapy regimens. Regardless, for well-selected patients with NSCLC (ie, peripheral primary tumors and limited mediastinal/hilar adenopathy), the convenience of hypofractionated radiotherapy regimens may offer an appropriate treatment option. Trial Registration ClinicalTrials.gov Identifier: NCT01459497.
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Affiliation(s)
- Puneeth Iyengar
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Elizabeth Zhang-Velten
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Laurence Court
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Kenneth Westover
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Yulong Yan
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Mu-Han Lin
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Zhenyu Xiong
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Mehul Patel
- Department of Radiation Oncology, Baylor Scott & White Memorial Hospital, Temple, Texas
| | - Douglas Rivera
- Department of Radiation Oncology, Austin Cancer Center, Austin, Texas
| | - Joe Chang
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Mark Saunders
- Department of Radiation Oncology, Texas Oncology Tyler, Tyler
| | - Anand Shivnani
- Department of Radiation Oncology, Texas Oncology Sherman, Sherman
| | - Andrew Lee
- Department of Radiation Oncology, Texas Center for Proton Therapy, Irving
| | - Randall Hughes
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - David Gerber
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Jonathan Dowell
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Ang Gao
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - John Heinzerling
- Department of Radiation Oncology, Levine Cancer Institute, Atrium Heath, Charlotte, North Carolina
| | - Ying Li
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Chul Ahn
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Hak Choy
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
| | - Robert Timmerman
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Medical Oncology, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas.,Department of Biostatistics, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas
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33
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Hani U, Osmani RAM, Siddiqua A, Wahab S, Batool S, Ather H, Sheraba N, Alqahtani A. A systematic study of novel drug delivery mechanisms and treatment strategies for pancreatic cancer. J Drug Deliv Sci Technol 2021. [DOI: 10.1016/j.jddst.2021.102539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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34
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Lee SL, Hall WA, Morris ZS, Christensen L, Bassetti M. MRI-Guided Radiation Therapy. ADVANCES IN ONCOLOGY 2021; 1:29-39. [PMID: 37064601 PMCID: PMC10104451 DOI: 10.1016/j.yao.2021.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Affiliation(s)
- Sangjune Laurence Lee
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, WI, USA
- Department of Oncology, Division of Radiation Oncology, University of Calgary, Calgary, AB, Canada
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zachary S. Morris
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Leslie Christensen
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Michael Bassetti
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, WI, USA
- Corresponding author. Department of Human Oncology, University of Wisconsin, University Hospital L7/B36, 600 Highland Avenue, Madison, WI 53792.
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Ryckman JM, Reames BN, Klute KA, Hall WA, Baine MJ, Abdel-Wahab M, Lin C. The timing and design of stereotactic radiotherapy approaches as a part of neoadjuvant therapy in pancreatic cancer: Is it time for change? Clin Transl Radiat Oncol 2021; 28:124-128. [PMID: 33981865 PMCID: PMC8085778 DOI: 10.1016/j.ctro.2021.04.002] [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: 02/04/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022] Open
Abstract
Stereotactic Radiotherapy (SRT) over 5-15 days can be interdigitated without delaying chemotherapy. Bridging chemotherapy may allow for extended intervals to surgery, potentially improving sterilization of surgical margins and overall survival. SRT for pancreatic adenocarcinoma should not be limited to the tumor, and should consider hypofractionated approaches to regional nodes.
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Affiliation(s)
- Jeffrey M. Ryckman
- Department of Radiation Oncology, West Virginia University Cancer Institute, Parkersburg, WV, USA
| | - Bradley N. Reames
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kelsey A. Klute
- Department of Medical Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - William A. Hall
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael J. Baine
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - May Abdel-Wahab
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Chi Lin
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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36
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Ghaly M, Gogineni E, Herman J, Saif MW. New Potential Options for SBRT in Pancreatic Cancer. CANCER MEDICINE JOURNAL 2021; 4:41-50. [PMID: 34355218 PMCID: PMC8336074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Stereotactic body radiotherapy (SBRT) is an emerging treatment option for patients with pancreatic cancer, as it can provide a therapeutic benefit with significant advantages for patients' quality of life over standard conventional chemoradiation (CRT). The objective of this review is to present alternative clinical settings in which SBRT may benefit patients with pancreatic cancer. These include palliation of pain, elderly patients who are not surgical candidates, local therapy in oligometastatic cases and salvaging local failures after surgery or external beam radiation. We will review these individually and provide supporting literature for each.
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Affiliation(s)
- Maged Ghaly
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Emile Gogineni
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Joseph Herman
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
| | - Muhammad W Saif
- Northwell Health Cancer Institute, Lake Success, NY 11042, USA
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Wang W, Sheng Y, Palta M, Czito B, Willett C, Hito M, Yin FF, Wu Q, Ge Y, Wu QJ. Deep Learning-Based Fluence Map Prediction for Pancreas Stereotactic Body Radiation Therapy With Simultaneous Integrated Boost. Adv Radiat Oncol 2021; 6:100672. [PMID: 33997484 PMCID: PMC8099762 DOI: 10.1016/j.adro.2021.100672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/29/2020] [Accepted: 01/27/2021] [Indexed: 02/03/2023] Open
Abstract
Purpose Treatment planning for pancreas stereotactic body radiation therapy (SBRT) is a challenging task, especially with simultaneous integrated boost treatment approaches. We propose a deep learning (DL) framework to accurately predict fluence maps from patient anatomy and directly generate intensity modulated radiation therapy plans. Methods and Materials The framework employs 2 convolutional neural networks (CNNs) to sequentially generate beam dose prediction and fluence map prediction, creating a deliverable 9-beam intensity modulated radiation therapy plan. Within the beam dose prediction CNN, axial slices of combined structure contour masks are used to predict 3-dimensional (3D) beam doses for each beam. Each 3D beam dose is projected along its beam’s-eye-view to form a 2D beam dose map, which is subsequently used by the fluence map prediction CNN to predict its fluence map. Finally, the 9 predicted fluence maps are imported into the treatment planning system to finalize the plan by leaf sequencing and dose calculation. One hundred patients receiving pancreas SBRT were retrospectively collected for this study. Benchmark plans with unified simultaneous integrated boost prescription (25/33 Gy) were manually optimized for each case. The data set was split into 80/20 cases for training and testing. We evaluated the proposed DL framework by assessing both the fluence maps and the final predicted plans. Further, clinical acceptability of the plans was evaluated by a physician specializing in gastrointestinal cancer. Results The DL-based planning was, on average, completed in under 2 minutes. In testing, the predicted plans achieved similar dose distribution compared with the benchmark plans (-1.5% deviation for planning target volume 33 V33Gy), with slightly higher planning target volume maximum (+1.03 Gy) and organ at risk maximum (+0.95 Gy) doses. After renormalization, the physician rated 19 cases clinically acceptable and 1 case requiring minor improvement. Conclusions The DL framework can effectively plan pancreas SBRT cases within 2 minutes. The predicted plans are clinically deliverable, with plan quality approaching that of manual planning.
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Affiliation(s)
- Wentao Wang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Medical Physics Graduate Program, Duke University, Durham, North Carolina
| | - Yang Sheng
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Manisha Palta
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Brian Czito
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Christopher Willett
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Martin Hito
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Department of Computer Science, Princeton University, New Jersey
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Medical Physics Graduate Program, Duke University, Durham, North Carolina
| | - Qiuwen Wu
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Medical Physics Graduate Program, Duke University, Durham, North Carolina
| | - Yaorong Ge
- Department of Software and Information Systems, University of North Carolina at Charlotte, Charlotte, North Carolina
| | - Q Jackie Wu
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.,Medical Physics Graduate Program, Duke University, Durham, North Carolina
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Mazzarotto R, Simoni N, Guariglia S, Rossi G, Micera R, De Robertis R, Pierelli A, Zivelonghi E, Malleo G, Paiella S, Salvia R, Cavedon C, Milella M, Bassi C. Dosimetric Feasibility Study of Dose Escalated Stereotactic Body Radiation Therapy (SBRT) in Locally Advanced Pancreatic Cancer (LAPC) Patients: It Is Time to Raise the Bar. Front Oncol 2020; 10:600940. [PMID: 33392093 PMCID: PMC7773844 DOI: 10.3389/fonc.2020.600940] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/17/2020] [Indexed: 12/12/2022] Open
Abstract
Background and Objective To assess the dosimetric feasibility of a stereotactic body radiotherapy (SBRT) dose escalated protocol, with a simultaneous integrated boost (SIB) and a simultaneous integrated protection (SIP) approach, in patients with locally advanced pancreatic cancer (LAPC). Material and Methods Twenty LAPC lesions, previously treated with SBRT at our Institution, were re-planned. The original prescribed and administered dose was 50/30/25 Gy in five fractions to PTVsib (tumor-vessel interface [TVI])/PTVt (tumor volume)/PTVsip (overlap area between PTVt and planning organs at risk volume [PRVoars]), respectively. At re-planning, the prescribed dose was escalated up to 60/40/33 Gy in five fractions to PTVsib/PTVt/PTVsip, respectively. All plans were performed using an inspiration breath hold (IBH) technique and generated with volumetric modulated arc therapy (VMAT). Well-established and accepted OAR dose constraints were used (D0.5cc < 33 Gy for luminal OARs and D0.5cc < 38 Gy for corresponding PRVoars). The primary end-point was to achieve a median dose equal to the prescription dose for the PTVsib with D98≥ 95% (95% of prescription dose is the minimum dose), and a coverage for PTVt and PTVsip of D95≥95%, with minor deviations in OAR dose constraints in < 10% of the plans. Results PTVsib median (± SD) dose/D95/conformity index (CI) were 60.54 (± 0.85) Gy/58.96 (± 0.86) Gy/0.99 (± 0.01), respectively; whilst PTVt median (± SD) dose/D95 were 44.51 (± 2.69) Gy/38.44 (± 0.82) Gy, and PTVsip median (± SD) dose/D95 were 35.18 (± 1.42) Gy/33.01 (± 0.84) Gy, respectively. With regard to OARs, median (± SD) maximum dose (D0.5cc) to duodenum/stomach/bowel was 29.31 (± 5.72) Gy/25.29 (± 6.90) Gy/27.03 (± 5.67) Gy, respectively. A minor acceptable deviation was found for a single plan (bowel and duodenum D0.5cc=34.8 Gy). V38 < 0.5 cc was achieved for all PRV luminal OARs. Conclusions In LAPC patients SBRT, with a SIB/SIP dose escalation approach up to 60/40/33 Gy in five fractions to PTVsib/PTVt/PTVsip, respectively, is dosimetrically feasible with adequate PTVs coverage and respect for OAR dose constraints.
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Affiliation(s)
- Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Renato Micera
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | | | - Alessio Pierelli
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Emanuele Zivelonghi
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Michele Milella
- Department of Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
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39
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Zhu X, Cao Y, Su T, Zhu X, Ju X, Zhao X, Jiang L, Ye Y, Cao F, Qing S, Zhang H. Failure patterns and outcomes of dose escalation of stereotactic body radiotherapy for locally advanced pancreatic cancer: a multicenter cohort study. Ther Adv Med Oncol 2020; 12:1758835920977155. [PMID: 33403017 PMCID: PMC7739203 DOI: 10.1177/1758835920977155] [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: 05/24/2020] [Accepted: 11/05/2020] [Indexed: 12/30/2022] Open
Abstract
Objective This study aims to compare recurrence patterns and outcomes of biologically effective dose (BED10, α/β = 10) of 60-70 Gy with those of a BED10 >70 Gy for locally advanced pancreatic cancer (LAPC). Methods Patients from three centers with a biopsy and a radiographically proven LAPC were retrospectively included and data were prospectively collected from June 2012 to June 2019. Radiotherapy was delivered by stereotactic body radiation therapy. Recurrences were categorized as in-field, marginal, and outside-the-field recurrence. Patients in two groups were required to receive abdominal enhanced contrast CT or MRI every 2-3 months and CA19-9 examinations every month during follow-up. Treatment-related toxicities were evaluated every month. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Results After propensity score matching, there were 486 patients in each group. The median prescription dose of the two groups was 37 Gy/5-8 f (range: 36-40.8 Gy/5-8 f) and 42 Gy/5-8 f (range: 40-49.6 Gy/5-8 f), respectively. The median OS of patients with a BED10 >70 Gy and a BED10 60-70 Gy was 20.3 months (95% CI: 19.1-21.5 months) and 18.2 months (95% CI: 17.8-18.6 months) respectively (p < 0.001). The median PFS of the two cohorts was 15.4 months (95% CI: 14.2-16.6 months) and 13.3 months (95% CI: 12.9-13.7 months) respectively (p < 0.001). A higher incidence of in-field and marginal recurrence was found in patients with BED10 of 60-70 Gy (in-field: 97/486 versus 72/486, p = 0.034; marginal: 109/486 versus 84/486, p = 0.044). However, more patients with BED10 >70 Gy had grade 2 or 3 acute (87/486 versus 64/486, p = 0.042) and late gastrointestinal toxicities (77/486 versus 55/486, p = 0.039) than those with BED10 of 60-70 Gy. Conclusion BED10 >70 Gy was found to have the best survival benefits along with a higher incidence of acute and late gastrointestinal toxicities. Therefore, a higher dose may be required in the case of patients' good tolerance.
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Affiliation(s)
- Xiaofei Zhu
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Yangsen Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Tingshi Su
- Department of Radiation Oncology, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xixu Zhu
- Department of Radiation Oncology, General Hospital of Eastern Theater Command, Nanjing, Jiangsu, China
| | - Xiaoping Ju
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Xianzhi Zhao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Lingong Jiang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Yusheng Ye
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Fei Cao
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Shuiwang Qing
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
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Moningi S, Abi Jaoude J, Kouzy R, Lin D, Nguyen ND, Garcia Garcia CJ, Phan JL, Avila S, Smani D, Cazacu IM, Singh BS, Smith GL, Holliday EB, Koay EJ, Das P, Bhutani MS, Herman JM, Minsky BD, Koong AC, Taniguchi CM. Impact of Fiducial Marker Placement Before Stereotactic Body Radiation Therapy on Clinical Outcomes in Patients With Pancreatic Cancer. Adv Radiat Oncol 2020; 6:100621. [PMID: 33912734 PMCID: PMC8071717 DOI: 10.1016/j.adro.2020.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Localized pancreatic cancer is commonly treated with stereotactic body radiation therapy (SBRT), which often requires the placement of fiducial markers. We compared the clinical outcomes of patients with and without fiducial markers. Methods and Materials We retrospectively collected data on patients with pancreatic cancer treated with neoadjuvant SBRT at a single institution. Patients were divided into 2 groups based on the placement of a fiducial marker. Local recurrence was the primary outcome. Time to event endpoints were analyzed using COX regression. Results We included 96 patients with unresectable pancreatic cancer: 46 patients (47.9%) did not have a fiducial marker, and 50 patients (52.1%) had a fiducial placed. Patients in the fiducial group were older and had more locally advanced pancreatic cancer compared with those who did not have a fiducial placed. Most patients in both groups (92.7%) received chemotherapy before SBRT treatment. SBRT was delivered to a median of 36 Gy over 5 fractions in the no-fiducial group, and 38 Gy over 5 fractions in the fiducial group. At a median follow-up of 20 months, local recurrence was similar irrespective of fiducial placement (adjusted hazard ratio [aHR] 0.6, 95% CI 0.3-1.3, P = .59). Furthermore, no difference in overall survival was noted between the 2 groups (aHR 0.8, 95% CI 0.3-1.9, P = .65). In patients who eventually underwent surgery post-SBRT, no difference in surgical margins (P = .40) or lymphovascular invasion (P = .76) was noted between the 2 groups. No patient developed acute pancreatitis after fiducial placement. Conclusions Our data suggest that the use of fiducial markers does not negatively affect clinical outcomes in patients with localized pancreatic cancer. Prospective confirmation of our results is still needed.
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Affiliation(s)
- Shalini Moningi
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Ramez Kouzy
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Lin
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | | | - Jae L Phan
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Santiago Avila
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel Smani
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Irina M Cazacu
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ben S Singh
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emma B Holliday
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eugene J Koay
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, New York
| | - Bruce D Minsky
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Albert C Koong
- University of Texas MD Anderson Cancer Center, Houston, Texas
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Grossberg AJ, Chu LC, Deig CR, Fishman EK, Hwang WL, Maitra A, Marks DL, Mehta A, Nabavizadeh N, Simeone DM, Weekes CD, Thomas CR. Multidisciplinary standards of care and recent progress in pancreatic ductal adenocarcinoma. CA Cancer J Clin 2020; 70:375-403. [PMID: 32683683 PMCID: PMC7722002 DOI: 10.3322/caac.21626] [Citation(s) in RCA: 237] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Despite tremendous gains in the molecular understanding of exocrine pancreatic cancer, the prognosis for this disease remains very poor, largely because of delayed disease detection and limited effectiveness of systemic therapies. Both incidence rates and mortality rates for pancreatic cancer have increased during the past decade, in contrast to most other solid tumor types. Recent improvements in multimodality care have substantially improved overall survival, local control, and metastasis-free survival for patients who have localized tumors that are amenable to surgical resection. The widening gap in prognosis between patients with resectable and unresectable or metastatic disease reinforces the importance of detecting pancreatic cancer sooner to improve outcomes. Furthermore, the developing use of therapies that target tumor-specific molecular vulnerabilities may offer improved disease control for patients with advanced disease. Finally, the substantial morbidity associated with pancreatic cancer, including wasting, fatigue, and pain, remains an under-addressed component of this disease, which powerfully affects quality of life and limits tolerance to aggressive therapies. In this article, the authors review the current multidisciplinary standards of care in pancreatic cancer with a focus on emerging concepts in pancreatic cancer detection, precision therapy, and survivorship.
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Affiliation(s)
- Aaron J. Grossberg
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Cancer Early Detection Advanced Research Center, Oregon Health & Science University, Portland, OR
| | - Linda C. Chu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher R. Deig
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Eliot K. Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William L. Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
- Broad Institute of Harvard and MIT, Cambridge, MA
| | - Anirban Maitra
- Departments of Pathology and Translational Molecular Pathology, Sheikh Ahmed Pancreatic Cancer Research Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel L. Marks
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Department of Pediatrics and Pape Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR
| | - Arnav Mehta
- Broad Institute of Harvard and MIT, Cambridge, MA
- Dana Farber Cancer Institute, Boston, MA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Diane M. Simeone
- Departments of Surgery and Pathology, Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Colin D. Weekes
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles R. Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
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42
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Basics and Frontiers on Pancreatic Cancer for Radiation Oncology: Target Delineation, SBRT, SIB technique, MRgRT, Particle Therapy, Immunotherapy and Clinical Guidelines. Cancers (Basel) 2020; 12:cancers12071729. [PMID: 32610592 PMCID: PMC7407382 DOI: 10.3390/cancers12071729] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/17/2022] Open
Abstract
Pancreatic cancer represents a modern oncological urgency. Its management is aimed to both distal and local disease control. Resectability is the cornerstone of treatment aim. It influences the clinical presentation’s definitions as up-front resectable, borderline resectable and locally advanced (unresectable). The main treatment categories are neoadjuvant (preoperative), definitive and adjuvant (postoperative). This review will focus on (i) the current indications by the available national and international guidelines; (ii) the current standard indications for target volume delineation in radiotherapy (RT); (iii) the emerging modern technologies (including particle therapy and Magnetic Resonance [MR]-guided-RT); (iv) stereotactic body radiotherapy (SBRT), as the most promising technical delivery application of RT in this framework; (v) a particularly promising dose delivery technique called simultaneous integrated boost (SIB); and (vi) a multimodal integration opportunity: the combination of RT with immunotherapy.
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43
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Abi Jaoude J, Kouzy R, Nguyen ND, Lin D, Noticewala SS, Ludmir EB, Taniguchi CM. Radiation therapy for patients with locally advanced pancreatic cancer: Evolving techniques and treatment strategies. Curr Probl Cancer 2020; 44:100607. [PMID: 32471736 DOI: 10.1016/j.currproblcancer.2020.100607] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022]
Abstract
Despite ongoing efforts, patients with locally advanced pancreatic cancer (LAPC) continue to have a dismal prognosis. Such tumors are unresectable, and optimal treatment with chemotherapy and/or radiation therapy is still not established. While chemotherapy is conventionally aimed at preventing metastatic spread of disease, radiation therapy acts locally, improving local control which can potentially improve overall survival and most importantly quality of life. Here, we aim to review the primary literature assessing the role of diverse radiation therapy strategies for patients with LAPC. Many radiation regimens can be considered, and no standard treatment has demonstrated a clear improvement in clinical outcomes. We advise that the modality of choice be dependent on the availability of equipment, the dose and fractionation of treatment, as well as the dose received by normal tissue. Moreover, a candid discussion with the patient concerning treatment goals is equally as essential. Three notable strategies for LAPC are intensity-modulated radiation therapy, volumetric modulated arc therapy, and proton. These radiation modalities tend to have improved dose distribution to the target volumes, while minimizing the radiation dose to surrounding normal tissues. Stereotactic body radiation therapy can also be considered in LAPC patients in cases where the tumor does not invade the duodenum or other neighboring structures. Because of the high doses delivered by stereotactic body radiation therapy, proper respiratory and tumor motion management should be implemented to reduce collateral radiation dosing. Despite improved clinical outcomes with modern radiation modalities, evolving techniques, and more accurate planning, future studies remain essential to elucidate the optimal role for radiation therapy among patients with LAPC.
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Affiliation(s)
| | - Ramez Kouzy
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Daniel Lin
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Ethan B Ludmir
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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44
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Simcock R, Thomas TV, Estes C, Filippi AR, Katz MA, Pereira IJ, Saeed H. COVID-19: Global radiation oncology's targeted response for pandemic preparedness. Clin Transl Radiat Oncol 2020; 22:55-68. [PMID: 32274425 PMCID: PMC7102593 DOI: 10.1016/j.ctro.2020.03.009] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/22/2020] [Accepted: 03/22/2020] [Indexed: 02/06/2023] Open
Abstract
As the global COVID-19 pandemic escalates there is a need within radiation oncology to work to support our patients in the best way possible. Measures are required to reduce infection spread between patients and within the workforce. Departments need contingency planning to create capacity and continue essential treatments despite a reduced workforce. The #radonc community held an urgent online journal club on Twitter in March 2020 to discuss these issues and create some consensus on crucial next steps. There were 121 global contributors. This document summarises these discussions around themes of infection prevention, rationalisation of workload and working practice in the presence of infection.
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Affiliation(s)
| | | | | | - Andrea R Filippi
- Radiation Oncology, Fondazione IRCCS Policlinico San Matteo and University of Pavia, Pavia, Italy
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