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Hiroshima Y, Kondo M, Sawada T, Hoshi S, Okubo R, Iizumi T, Numajiri H, Okumura T, Sakurai H. Analysis of the cost-effectiveness of proton beam therapy for unresectable pancreatic cancer in Japan. Cancer Med 2023; 12:20450-20458. [PMID: 37795771 PMCID: PMC10652344 DOI: 10.1002/cam4.6611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 08/28/2023] [Accepted: 09/22/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Proton beam therapy (PBT) has recently been included in Japan's social health insurance benefits package. This study aimed to determine the cost-effectiveness of PBT for unresectable, locally advanced pancreatic cancer (LAPC) as a replacement for conventional photon radiotherapy (RT). METHODS We estimated the incremental cost-effectiveness ratio (ICER) of PBT as a replacement for three-dimensional conformal RT (3DCRT), a conventional photon RT, using clinical evidence in the literature and expense complemented by expert opinions. We used a decision tree and an economic and Markov model to illustrate the disease courses followed by LAPC patients. Effectiveness was estimated as quality-adjusted life years (QALY) using utility weights for the health state. Social insurance fees were calculated as the costs. The stability of the ICER against the assumptions made was appraised using sensitivity analyses. RESULTS The effectiveness of PBT and 3DCRT was 1.67610615 and 0.97181271 QALY, respectively. The ICER was estimated to be ¥5,376,915 (US$46,756) per QALY. According to the suggested threshold for anti-cancer therapy from the Japanese authority of ¥7,500,000 (US$65,217) per QALY gain, such a replacement would be considered cost-effective. The one-way and probabilistic sensitivity analyses demonstrated stability of the base-case ICER. CONCLUSION PBT, as a replacement for conventional photon radiotherapy, is cost-effective and justifiable as an efficient use of finite healthcare resources. Making it a standard treatment option and available to every patient in Japan is socially acceptable from the perspective of health economics.
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Affiliation(s)
- Yuichi Hiroshima
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- QST hospital, National Institutes for Quantum and Radiological Sciences and TechnologyChibaChibaJapan
- Department of Radiation Oncology, Ibaraki Prefectural Central HospitalKasamaIbarakiJapan
| | - Masahide Kondo
- Department of Health Care Policy and Health Economics, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Takuya Sawada
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Shu‐ling Hoshi
- Department of Health Care Policy and Health Economics, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Reiko Okubo
- Department of Health Care Policy and Health Economics, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Department of Clinical Laboratory MedicineUniversity of Tsukuba HospitalTsukubaIbarakiJapan
- Department of Nephrology, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Takashi Iizumi
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Haruko Numajiri
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
| | - Toshiyuki Okumura
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
- Department of Radiation Oncology, Ibaraki Prefectural Central HospitalKasamaIbarakiJapan
| | - Hideyuki Sakurai
- Department of Radiation Oncology & Proton Medical Research Center, Faculty of MedicineUniversity of TsukubaTsukubaIbarakiJapan
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Eckstein J, Choi JI, Lozano A, Ohri N, Press R, Hasan S, Kabarriti R, Chang J, Urbanic J, Durci M, Mohammed N, Stevens C, Tsai H, Apisarnthanarax S, Regine W, Vargas C, Nichols R, Herman J, Simone CB, Chhabra A. Proton Therapy for Unresectable and Medically Inoperable Locally Advanced Pancreatic Cancer: Results From a Multi-Institutional Prospective Registry. Adv Radiat Oncol 2023; 8:101250. [PMID: 37408677 PMCID: PMC10318270 DOI: 10.1016/j.adro.2023.101250] [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: 11/22/2022] [Accepted: 04/11/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Compared with photon-based techniques, proton beam radiation therapy (PBT) may improve the therapeutic ratio of radiation therapy (RT) for locally advanced pancreatic cancer (LAPC), but available data have been limited to single-institutional experiences. This study examined the toxicity, survival, and disease control rates among patients enrolled in a multi-institutional prospective registry study and treated with PBT for LAPC. Methods and Materials Between March 2013 and November 2019, 19 patients with inoperable disease across 7 institutions underwent PBT with definitive intent for LAPC. Patients received a median radiation dose/fractionation of 54 Gy/30 fractions (range, 50.4-60.0 Gy/19-33 fractions). Most received prior (68.4%) or concurrent (78.9%) chemotherapy. Patients were assessed prospectively for toxicities using National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0. Kaplan-Meier analysis was used to analyze overall survival, locoregional recurrence-free survival, time to locoregional recurrence, distant metastasis-free survival, and time to new progression or metastasis for the adenocarcinoma cohort (17 patients). Results No patients experienced grade ≥3 acute or chronic treatment-related adverse events. Grade 1 and 2 adverse events occurred in 78.7% and 21.3% of patients, respectively. Median overall survival, locoregional recurrence-free survival, distant metastasis-free survival, and time to new progression or metastasis were 14.6, 11.0, 11.0, and 13.9 months, respectively. Freedom from locoregional recurrence at 2 years was 81.7%. All patients completed treatment with one requiring a RT break for stent placement. Conclusions Proton beam RT for LAPC offered excellent tolerability while still maintaining disease control and survival rates comparable with dose-escalated photon-based RT. These findings are consistent with the known physical and dosimetric advantages offered by proton therapy, but the conclusions are limited owing to the patient sample size. Further clinical studies incorporating dose-escalated PBT are warranted to evaluate whether these dosimetric advantages translate into clinically meaningful benefits.
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Affiliation(s)
- Jacob Eckstein
- Northwell Health, Department of Radiation Medicine, New Hyde Park, New York
| | | | | | - Nitin Ohri
- Montefiore Einstein Cancer Center, Department of Radiation Oncology, Bronx, New York
| | | | | | - Rafi Kabarriti
- Montefiore Einstein Cancer Center, Department of Radiation Oncology, Bronx, New York
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, Oklahoma
| | - James Urbanic
- University of California, Department of Radiation Medicine and Applied Sciences, San Diego, California
| | - Michael Durci
- Willis Knighton Cancer Center, Shreveport, Louisiana
| | | | - Craig Stevens
- Oakland University William Beaumont School of Medicine, Department of Radiation Oncology, Royal Oak, Michigan
| | - Henry Tsai
- Princeton Radiation Oncology, Somerset, New Jersey
| | - Smith Apisarnthanarax
- University of Washington Medicine, Department of Radiation Oncology, Seattle, Washington
| | - William Regine
- University of Maryland School of Medicine, Department of Radiation Oncology, Baltimore, Maryland
| | - Carlos Vargas
- Mayo Clinic, Department of Radiation Oncology, Rochester, Minnesota
| | - Romaine Nichols
- University of Florida Protons, Department of Radiation Oncology, Gainesville, Florida
| | - Joseph Herman
- Northwell Health, Department of Radiation Medicine, New Hyde Park, New York
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Aploks K, Kim M, Stroever S, Ostapenko A, Sim YB, Sooriyakumar A, Rahimi-Ardabily A, Seshadri R, Dong XD. Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss. World J Gastrointest Surg 2023; 15:1663-1672. [PMID: 37701691 PMCID: PMC10494586 DOI: 10.4240/wjgs.v15.i8.1663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/12/2023] [Accepted: 06/12/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Pancreatic adenocarcinoma is currently the fourth leading cause of cancer-related deaths in the United States. In patients with "borderline resectable" disease, current National Comprehensive Cancer Center guidelines recommend the use of neoadjuvant chemoradiation prior to a pancreaticoduodenectomy. Although neoadjuvant radiotherapy may improve negative margin resection rate, it is theorized that its administration increases operative times and complexity. AIM To investigate the association between neoadjuvant radiotherapy and 30-d morbidity and mortality outcomes among patients receiving a pancreaticoduodenectomy for pancreatic adenocarcinoma. METHODS Patients listed in the 2015-2019 National Surgery Quality Improvement Program data set, who received a pancreaticoduodenectomy for pancreatic adenocarcinoma, were divided into two groups based off neoadjuvant radiotherapy status. Multivariable regression was used to determine if there is a significant correlation between neoadjuvant radiotherapy, perioperative blood transfusion status, total operative time, and other perioperative outcomes. RESULTS Of the 11458 patients included in the study, 1470 (12.8%) underwent neoadjuvant radiotherapy. Patients who received neoadjuvant radiotherapy were significantly more likely to require a perioperative blood transfusion [adjusted odds ratio (aOR) = 1.58, 95% confidence interval (CI): 1.37-1.82; P < 0.001] and have longer surgeries (insulin receptor-related receptor = 1.14, 95%CI: 1.11-1.16; P < 0.001), while simultaneously having lower rates of organ space infections (aOR = 0.80, 95%CI: 0.66-0.97; P = 0.02) and pancreatic fistula formation (aOR = 0.50, 95%CI: 0.40-0.63; P < 0.001) compared to those who underwent surgery alone. CONCLUSION Neoadjuvant radiotherapy, while not associated with increased mortality, will impact the complexity of surgical resection in patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Krist Aploks
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Minha Kim
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Stephanie Stroever
- Department of Research and Innovation, Nuvance Health, Danbury, CT 06810, United States
| | - Alexander Ostapenko
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Young Bo Sim
- Department of General Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | | | | | - Ramanathan Seshadri
- Division of Surgical Oncology/Hepato-Pancreato-Biliary Surgery, Danbury Hospital, Danbury, CT 06810, United States
| | - Xiang Da Dong
- Division of Surgical Oncology/Hepato-Pancreato-Biliary Surgery, Danbury Hospital, Danbury, CT 06810, United States
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Ami K, Terashima K, Ishida J, Suga M, Okawa T, Takahashi D, Park S, Matsuo Y, Nanno Y, Tokumaru S, Okimoto T, Toyama H, Fukumoto T. Proton radiotherapy as a treatment strategy to increase survival in locally advanced pancreatic cancer in the body and tail: a retrospective study. Radiat Oncol 2023; 18:131. [PMID: 37553705 PMCID: PMC10408146 DOI: 10.1186/s13014-023-02301-9] [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: 05/19/2023] [Accepted: 06/19/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Long-term outcomes and prognostic factors of proton radiotherapy for locally advanced pancreatic cancer (LAPC) in the body and tail are still unknown. The aim of this study was to determine the prognostic factors after proton radiotherapy in a large group of patients with LAPC in the body and tail. METHODS The medical records of 200 patients with LAPC in the body and tail who underwent proton radiotherapy between February 2009 and January 2021 at the Hyogo Ion Beam Medical Center were retrospectively reviewed to identify prognostic factors that contribute to long-term survival. RESULTS The overall survival rate at 1- and 2-year after PT was 69.6% and 35.4% with a median overall survival of 18.4 months. The 1- and 2-year local progression-free, and progression-free survival rates were 84.3% and 68.0%, and 44.3% and 19.4%, respectively. In multivariate analysis, superior mesenteric artery (SMA) invasion (SMA only invasion vs. celiac artery only invasion; P = 0.049: SMA and celiac artery invasion vs. celiac artery only invasion; P = 0.017), carbohydrate antigen 19-9 (CA 19-9) level ≥ 231.9 U/mL (P = 0.001), anterior peripancreatic invasion (P = 0.006), and incomplete scheduled concurrent chemotherapy (P = 0.009) were statistically significant prognostic factors for overall survival. There was no significant difference in local progression-free survival; however, distant metastasis-free survival was statistically worse in patients with prognostic factors than in those without. CONCLUSIONS Proton radiotherapy for LAPC in the body and tail may be a valuable multidisciplinary treatment option. Patients with SMA invasion, higher pre-proton radiotherapy serum CA 19-9 level, anterior peripancreatic invasion, or incomplete scheduled concurrent chemotherapy had worse overall survival because of worse distant metastasis-free survival, suggesting that distant metastases have a significant impact on overall survival in such patients. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Katsuya Ami
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Kazuki Terashima
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Jun Ishida
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Masaki Suga
- Department of Radiation Physics, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Taisuke Okawa
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Daiki Takahashi
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - SungChul Park
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Yoshiro Matsuo
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Yoshihide Nanno
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Sunao Tokumaru
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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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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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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7
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Calvo FA, Ayestaran A, Serrano J, Cambeiro M, Palma J, Meiriño R, Morcillo MA, Lapuente F, Chiva L, Aguilar B, Azcona D, Pedrero D, Pascau J, Delgado JM, Aristu J, Prezado Y. Practice-oriented solutions integrating intraoperative electron irradiation and personalized proton therapy for recurrent or unresectable cancers: Proof of concept and potential for dual FLASH effect. Front Oncol 2022; 12:1037262. [PMID: 36452493 PMCID: PMC9703091 DOI: 10.3389/fonc.2022.1037262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022] Open
Abstract
Background Oligo-recurrent disease has a consolidated evidence of long-term surviving patients due to the use of intense local cancer therapy. The latter combines real-time surgical exploration/resection with high-energy electron beam single dose of irradiation. This results in a very precise radiation dose deposit, which is an essential element of contemporary multidisciplinary individualized oncology. Methods Patient candidates to proton therapy were evaluated in Multidisciplinary Tumor Board to consider improved treatment options based on the institutional resources and expertise. Proton therapy was delivered by a synchrotron-based pencil beam scanning technology with energy levels from 70.2 to 228.7 MeV, whereas intraoperative electrons were generated in a miniaturized linear accelerator with dose rates ranging from 22 to 36 Gy/min (at Dmax) and energies from 6 to 12 MeV. Results In a period of 24 months, 327 patients were treated with proton therapy: 218 were adults, 97 had recurrent cancer, and 54 required re-irradiation. The specific radiation modalities selected in five cases included an integral strategy to optimize the local disease management by the combination of surgery, intraoperative electron boost, and external pencil beam proton therapy as components of the radiotherapy management. Recurrent cancer was present in four cases (cervix, sarcoma, melanoma, and rectum), and one patient had a primary unresectable locally advanced pancreatic adenocarcinoma. In re-irradiated patients (cervix and rectum), a tentative radical total dose was achieved by integrating beams of electrons (ranging from 10- to 20-Gy single dose) and protons (30 to 54-Gy Relative Biological Effectiveness (RBE), in 10-25 fractions). Conclusions Individual case solution strategies combining intraoperative electron radiation therapy and proton therapy for patients with oligo-recurrent or unresectable localized cancer are feasible. The potential of this combination can be clinically explored with electron and proton FLASH beams.
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Affiliation(s)
- Felipe A Calvo
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Adriana Ayestaran
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Javier Serrano
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Mauricio Cambeiro
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Jacobo Palma
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Rosa Meiriño
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Miguel A Morcillo
- Medical Applications Unit, Centro de Investigaciones Energéticas, Medioambientales y Tecnológicas (CIEMAT), Madrid, Spain
| | - Fernando Lapuente
- Department of Surgery, Clinica Universidad de Navarra, Madrid, Spain
| | - Luis Chiva
- Department of Gynecology and Obstretics, Clinica Universidad de Navarra, Madrid, Spain
| | - Borja Aguilar
- Department of Medical Physics, Clinica Universidad de Navarra, Madrid, Spain
| | - Diego Azcona
- Department of Medical Physics, Clinica Universidad de Navarra, Madrid, Spain
| | - Diego Pedrero
- Department of Medical Physics, Clinica Universidad de Navarra, Madrid, Spain
| | - Javier Pascau
- Department of Bioengineering and Aerospace Engineering, Universidad Carlos III de Madrid, Madrid, Spain
| | - José Miguel Delgado
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Javier Aristu
- Department of Radiation Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Yolanda Prezado
- Translational Research Department. Institut Curie, Université PSL, CNRS UMR, Inserm, Signalisation, Radiobiologie et Cancer, Orsay, France.,Université Paris-Saclay, CNRS UMR, Inserm, Signalisation, Radiobiologie et Cancer, Orsay, France
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8
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Song L, Xu C, Zhang T, Chen S, Shi Z, Hu S, Cheng B, Tong H, Wei G, Li X. Development and validation of a competing risk model for second primary pancreatic ductal adenocarcinoma: A population-based study. Front Surg 2022; 9:934148. [PMID: 36111234 PMCID: PMC9468218 DOI: 10.3389/fsurg.2022.934148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background With advances in early diagnosis and treatment, the number of cancer survivors continues to grow, and more and more cancer survivors face the threat of second primary cancer (SPM). Second primary pancreatic ductal adenocarcinoma (spPDAC) is an important subclass of SPM, but its prognostic characteristics are poorly understood. Methods A total of 5,439 spPDAC samples and 67,262 primary pancreatic ductal adenocarcinoma (pPDAC) samples were extracted from the SEER database for this study. Survival differences between spPDAC and pPDAC samples were compared using Kaplan–Meier curves and log-rank tests. The Fine and Gray proportional subdistributed hazard method was used to analyze potential associations between clinical variables and pancreatic ductal adenocarcinoma-specific death (PDACSD) and death from other causes. After that, the clinical variables significantly related to PDACSD were screened out to construct a competing risk nomogram, which was used to evaluate the probability of the occurrence of PDACSD. The C-index was used to evaluate the discriminative ability of the model. The area under the curve (AUC) was used to verify the discrimination of the model. The calibration curve was used to verify the calibration of the model. Decision curve analysis (DCA) was used to validate the clinical utility of the model. Results Compared with patients with spPDAC, the pPDAC sample had a better prognosis (p = 0.0017). Across all spPDAC samples, the three most common sites of first-present cancer were the prostate, breast, and digestive system. Age (p < 0.001), race (p = 0.006), interval (p = 0.016), location (p < 0.001), T stage (p = 0.003), M stage (p < 0.001), chemotherapy (p < 0.001), and radiotherapy (p = 0.006) were the clinical variables associated with PDACSD screened by multivariate competing risks analysis. The concordance index values for the training and validation sets were 0.665 (95% CI, 0.655, 0.675) and 0.666 (95% CI, 0.650, 0.682), respectively. AUC, calibration curve, and DCA indicated that the model we constructed had good discrimination, calibration, and clinical utility. Conclusions In conclusion, we first analyzed the impact of previous cancer history on prognosis. We then constructed a competing risk model that can predict the probability of developing PDACSD in spPDAC. This model has good discriminative ability, calibration, and clinical practicability and has certain guiding value for clinical decision-making.
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Ye Y, Zhu X, Zhao X, Jiang L, Cao Y, Zhang H. Biologically effective doses of 60-70Gy versus >70Gy of stereotactic body radiotherapy (SBRT) combined with chemotherapy in locally advanced pancreatic cancer: protocol of a single-centre, phase II clinical trial. BMJ Open 2022; 12:e049382. [PMID: 36038164 PMCID: PMC9438046 DOI: 10.1136/bmjopen-2021-049382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION There is a paucity of studies about whether dose escalation of stereotactic body radiation therapy (SBRT) prolongs survival compared with de-escalation for patients with locally advanced pancreatic cancer (LAPC). Therefore, the aim of the study is to compare the survival benefits of biologically effective dose (BED10, α/β=10) of 60-70 Gy with those of BED10 >70 Gy. METHODS AND ANALYSIS This study is a single-centre, phase II trial. Patients with LAPC are randomly allocated to receive SBRT with BED10 of 60-70 Gy or >70 Gy in 5-6 fractions combined with gemcitabine plus albumin-bound paclitaxel. The primary outcome is progression-free survival. The secondary outcomes are adverse events, local control and overall survival. ETHICS AND DISSEMINATION The trial protocol has been approved by the Ethics committee of Shanghai Changhai Hospital. The ethics number is CHEC2020-100. Study results will be disseminated through peer-reviewed journals and released in related medical conferences. TRIAL REGISTRATION NUMBERS NCT04603586.
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Affiliation(s)
- Yusheng Ye
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaofei Zhu
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xianzhi Zhao
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lingong Jiang
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yangsen Cao
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Huojun Zhang
- Department of Radiation Oncology, Changhai Hospital, Naval Medical University, Shanghai, China
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10
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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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11
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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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12
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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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13
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Rossi G, Altabella L, Simoni N, Benetti G, Rossi R, Venezia M, Paiella S, Malleo G, Salvia R, Guariglia S, Bassi C, Cavedon C, Mazzarotto R. Computed tomography-based radiomic to predict resectability in locally advanced pancreatic cancer treated with chemotherapy and radiotherapy. World J Gastrointest Oncol 2022; 14:703-715. [PMID: 35321278 PMCID: PMC8919018 DOI: 10.4251/wjgo.v14.i3.703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/06/2021] [Accepted: 02/13/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Surgical resection after neoadjuvant treatment is the main driver for improved survival in locally advanced pancreatic cancer (LAPC). However, the diagnostic performance of computed tomography (CT) imaging to evaluate the residual tumour burden at restaging after neoadjuvant therapy is low due to the difficulty in distinguishing neoplastic tissue from fibrous scar or inflammation. In this context, radiomics has gained popularity over conventional imaging as a complementary clinical tool capable of providing additional, unprecedented information regarding the intratumor heterogeneity and the residual neoplastic tissue, potentially serving in the therapeutic decision-making process.
AIM To assess the capability of radiomic features to predict surgical resection in LAPC treated with neoadjuvant chemotherapy and radiotherapy.
METHODS Patients with LAPC treated with intensive chemotherapy followed by ablative radiation therapy were retrospectively reviewed. One thousand six hundred and fifty-five radiomic features were extracted from planning CT inside the gross tumour volume. Both extracted features and clinical data contribute to create and validate the predictive model of resectability status. Patients were repeatedly divided into training and validation sets. The discriminating performance of each model, obtained applying a LASSO regression analysis, was assessed with the area under the receiver operating characteristic curve (AUC). The validated model was applied to the entire dataset to obtain the most significant features.
RESULTS Seventy-one patients were included in the analysis. Median age was 65 years and 57.8% of patients were male. All patients underwent induction chemotherapy followed by ablative radiotherapy, and 19 (26.8%) ultimately received surgical resection. After the first step of variable selections, a predictive model of resectability was developed with a median AUC for training and validation sets of 0.862 (95%CI: 0.792-0.921) and 0.853 (95%CI: 0.706-0.960), respectively. The validated model was applied to the entire dataset and 4 features were selected to build the model with predictive performance as measured using AUC of 0.944 (95%CI: 0.892-0.996).
CONCLUSION The present radiomic model could help predict resectability in LAPC after neoadjuvant chemotherapy and radiotherapy, potentially integrating clinical and morphological parameters in predicting surgical resection.
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Affiliation(s)
- Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Luisa Altabella
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Giulio Benetti
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Martina Venezia
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona 37126, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona 37126, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona 37126, Italy
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14
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Ogura Y, Terashima K, Nanno Y, Park S, Suga M, Takahashi D, Matsuo Y, Sulaiman NS, Tokumaru S, Okimoto T, Toyama H, Fukumoto T. Factors associated with long-term survival in gemcitabine-concurrent proton radiotherapy for non-metastatic locally advanced pancreatic cancer: a single-center retrospective study. Radiat Oncol 2022; 17:32. [PMID: 35144647 PMCID: PMC8832744 DOI: 10.1186/s13014-022-02001-w] [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: 11/09/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2022] Open
Abstract
Background Factors associated with long-term survival in gemcitabine-concurrent proton radiotherapy (GPT) for non-metastatic, locally advanced pancreatic cancer (LAPC) remain unclear. This study aimed to determine the factors associated with long-term survival in GPT for non-metastatic LAPC.
Methods The medical records of 123 patients with LAPC treated with GPT between February 2009 and December 2019 at Hyogo Ion Beam Medical Center were retrospectively reviewed to assess the factors associated with long-term survival outcomes. Results The median overall survival of the total cohort treated with GPT was 18.7 months. The 1- and 2-year overall, local progression-free, and progression-free survival rates were 70.4% and 35.7%, 78.2% and 59.0%, and 38.6% and 20.8%, respectively. Multivariate analysis revealed that LAPCs at the pancreatic body-tail and those without anterior peripancreatic invasion were independently associated with longer overall survival (P = 0.040 and P = 0.015, respectively). The median overall survival of patients with LAPC at the pancreatic body-tail and those with LAPC without anterior peripancreatic invasion were 24.1 and 28.1 months, respectively. LAPCs at the pancreatic body-tail had a higher volume ratio irradiated over 60 Gy equivalents at gross tumor volume than those at the pancreatic head (P < 0.001). LAPCs with anterior peripancreatic invasion had more peritoneal recurrence within 6 months after GTP than those without anterior peripancreatic invasion (P = 0.039). Conclusions GPT is a promising treatment option for patients with LAPC at the pancreatic body-tail and those with LAPC without anterior peripancreatic invasion.
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Affiliation(s)
- Yuta Ogura
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.,Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Kazuki Terashima
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Yoshihide Nanno
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - SungChul Park
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Masaki Suga
- Department of Radiation Physics, Hyogo Ion Bseam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Daiki Takahashi
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Yoshiro Matsuo
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Nor Shazrina Sulaiman
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Sunao Tokumaru
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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15
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Parisi S, Ferini G, Cacciola A, Lillo S, Tamburella C, Santacaterina A, Bottari A, Brogna A, Ferrantelli G, Pontoriero A, Minutoli F, Pergolizzi S. A non-surgical COMBO-therapy approach for locally advanced unresectable pancreatic adenocarcinoma: preliminary results of a prospective study. LA RADIOLOGIA MEDICA 2022; 127:214-219. [PMID: 35034325 DOI: 10.1007/s11547-021-01441-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022]
Abstract
In this short report we present a series of thirteen patients with locally advanced, unresectable, pancreatic cancer treated with a COMBO-Therapy consisting of: STEP-1: induction chemotherapy; STEP-2: concomitant chemoradiotherapy; STEP-3: stereotactic body radiotherapy boost. After four weeks from the end of each step all patients had a re-staging and a surgical re-evaluation. All patients completed STEP-1 and STEP-2. STEP-3 has been successfully delivered to 8/13 patients with a median dose of 12 Gy (range 10-21 Gy) in 1-3 fractions. The median LC was 20 months (range 10-32) with a 2-year LC of 72.9%, and none of the patients developed G3 acute or late toxicities. The median OS was 21.5 months (range 12-34), and the 2-year OS was 53.9%; the median PFS was 17.5 months (range 10-27). Our non-surgical COMBO-Therapy has demonstrated a feasible profile with good tolerance. Further prospective protocols are needed to confirm our preliminary results.
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Affiliation(s)
- Silvana Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | | | - Alberto Cacciola
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Sara Lillo
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy.
| | - Consuelo Tamburella
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | | | - Antonio Bottari
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Anna Brogna
- Unit of Medical Physics, University Hospital Policlinico "G. Martino", Messina, Italy
| | - Giacomo Ferrantelli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Antonio Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Fabio Minutoli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Stefano Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
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16
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Wolfe AR, Siedow M, Nalin A, DiCostanzo D, Miller ED, Diaz DA, Arnett A, Cloyd JM, Dillhoff M, Ejaz A, Tsung A, Williams TM. Increasing neutrophil-to-lymphocyte ratio following radiation is a poor prognostic factor and directly correlates with splenic radiation dose in pancreatic cancer. Radiother Oncol 2021; 158:207-214. [PMID: 33667588 DOI: 10.1016/j.radonc.2021.02.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/29/2021] [Accepted: 02/24/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Neutrophil-to-lymphocyte ratio has been correlated with clinical outcomes in many cancers. We investigated whether the delta-NLR (ΔNLR) following radiation therapy (RT) could predict achieving surgical resection and the overall survival (OS) of patients with borderline resectable (BRPC) and locally advanced pancreatic cancer (LAPC), and whether the splenic radiation dose impacted ΔNLR. METHODS/MATERIALS 101 patients with biopsy-proven BRPC or LAPC who received induction chemotherapy followed by RT were retrospectively enrolled. Following contouring of spleens, dose-volume histograms (DVHs) for splenic dosimetric parameters were calculated. Pre- and post-RT complete blood counts (CBC) within two weeks were recorded. Delta (Δ) values were calculated by subtracting the post-RT value from the pre-RT value. Cox regression survival analysis for pre and postradiation CBC values and OS was performed. Receiver operating curves (ROC) were generated and optimal cutoff points for highest sensitivity and specificity were identified. Kaplan-Meier curves for OS were generated. RESULTS On univariate Cox regression analysis, the only significant CBC value associated with OS was ΔNLR (HR 1.06, CI 1.03-1.09, p < 0.001). On multivariate analysis, ΔNLR, age, and completed resection all significantly predicted for worse OS (p < 0.05). ΔNLR significantly predicted achieving surgical resection (p = 0.04) and the optimal cutoff point for ΔNLR was 2.5. Patients with ΔNLR < 2.5 had significantly longer OS (log rank p = 0.046). Spleen radiation dose parameters were all significantly higher in patients with a ΔNLR ≥ 2.5. Optimal radiation cutoff points to predict a ΔNLR ≥ 2.5 were splenic Dmean of 308 cGy and V5 of 10.3%. CONCLUSIONS Among patients with BRPC or LAPC who have received induction chemotherapy, elevated ΔNLR after RT significantly predicts worse OS and decreased odds of achieving resection. Furthermore, ΔNLR is correlated with higher splenic doses, suggesting the spleen may be an important organ at risk.
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Affiliation(s)
- Adam R Wolfe
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Michael Siedow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ansel Nalin
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dominic DiCostanzo
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Eric D Miller
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Dayssy Alexandra Diaz
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Andrea Arnett
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, Ohio State University The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Mary Dillhoff
- Division of Surgical Oncology, Department of Surgery, Ohio State University The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, Ohio State University The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, Ohio State University The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Terence M Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, United States.
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A Third-Generation Adaptive Statistical Iterative Reconstruction for Contrast-Enhanced 4-Dimensional Dual-Energy Computed Tomography for Pancreatic Cancer. J Comput Assist Tomogr 2021; 45:18-23. [PMID: 31738200 DOI: 10.1097/rct.0000000000000942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective of this study was to assess the objective and subjective qualities of the contrast-enhanced 4-dimensional dual-energy computed tomography using adaptive statistical iterative reconstruction (ASiR) and ASiR-V. METHODS The virtual monochromatic images at 60 keV were reconstructed using filtered back projection, ASiR, and ASiR-V (10%-100%) for 14 patients with pancreatic cancer. The contrast-to-noise ratio (CNR) was calculated, and the subjective measurements were compared based on a 5-point score scale. RESULTS The ASiR-V yielded a significantly higher CNR than ASiR (P < 0.05). The subjective image quality (peak) was significantly improved (P < 0.01) with ASiR (50%) (3.8, 3.5, and 4.0; overall image quality, tumor delineation, and noise, respectively) and with ASiR-V (50%) (3.9, 3.5, and 4.2, respectively) compared with the filtered back projection (3.2, 3.2, and 3.0, respectively). CONCLUSIONS The ASiR-V yielded higher CNR than ASiR and provided the highest subjective scores regarding the overall image quality.
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Zhu X, Cao Y, Ju X, Zhao X, Jiang L, Ye Y, Shen Y, Cao F, Qing S, Zhang H. Personalized designs of adjuvant radiotherapy for pancreatic cancer based on molecular profiles. Cancer Sci 2021; 112:287-295. [PMID: 32418280 PMCID: PMC7780045 DOI: 10.1111/cas.14486] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/05/2020] [Accepted: 05/12/2020] [Indexed: 12/12/2022] Open
Abstract
This study aims to identify postoperative recurrence patterns of pancreatic cancer with different molecular profiles, which provides evidence for personalized target volumes of adjuvant radiotherapy. Patients with pathologically confirmed resectable pancreatic ductal adenocarcinoma were included. Recurrences were treated with stereotactic body radiation therapy. Immunohistochemical staining of Ki-67, P53, and programmed cell death-ligand 1 (PD-L1) was carried out. Both of the intensities of Ki-67 and P53 were classified as 10% or less, 11%-49%, and 50% or more. Eighty-nine patients had PD-L1 tested, stratified as TC0 and IC0, and TC1/2 or IC1/2. Distances with significant differences among different levels or beyond 10 mm were of interest. With the increasing intensity of Ki-67, the distance from the superior and posterior border of 80% recurrences to the celiac axis (CA) ranged from 10.1 to 13.8 mm and 9.2 to 11.0 mm. The distance from the inferior and posterior border of 80% recurrences to the superior mesenteric artery (SMA) ranged from 9.4 to 9.9 mm and 9.4 to 11.0 mm. Similarly, with the increasing intensity of P53, the distance from the superior and posterior border of 80% recurrences to the CA ranged from 9.7 to 13.2 mm and 10.1 to 10.6 mm. The distance from the inferior and anterior border of 80% recurrences to the SMA ranged from 9.5 to 9.9 mm and 8.6 to 9.4 mm. Regarding the increasing level of PD-L1, the distance from the superior border of 80% recurrences to the CA ranged from 10.9 to 13.5 mm. A biologically effective dose of more than 65 Gy to local recurrences was predictive of favorable outcomes in all levels of Ki-67, P53, and PD-L1. Nonuniform expansions of regions of interest based on different levels of molecular profiles to form target volumes could cover most recurrences, which might be feasible for adjuvant radiotherapy.
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Affiliation(s)
- Xiaofei Zhu
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Yangsen Cao
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Xiaoping Ju
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Xianzhi Zhao
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Lingong Jiang
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Yusheng Ye
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Yuxin Shen
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Fei Cao
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Shuiwang Qing
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
| | - Huojun Zhang
- Departmant of Radiation OncologyChanghai hospital affiliated to Navy Medical UniversityShanghaiChina
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19
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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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20
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Koay EJ, Hanania AN, Hall WA, Taniguchi CM, Rebueno N, Myrehaug S, Aitken KL, Dawson LA, Crane CH, Herman JM, Erickson B. Dose-Escalated Radiation Therapy for Pancreatic Cancer: A Simultaneous Integrated Boost Approach. Pract Radiat Oncol 2020; 10:e495-e507. [PMID: 32061993 PMCID: PMC7423616 DOI: 10.1016/j.prro.2020.01.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/17/2020] [Accepted: 01/27/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To provide a detailed description of practical approaches to dose escalation in pancreatic cancer. METHODS AND MATERIALS The current paper represents an international collaborative effort of radiation oncologists from the MR-linac consortium with expertise in pancreatic dose escalation. RESULTS A 15-fraction hypofractionated intensity modulated radiation therapy (67.5 Gy in 15 fractions) and 5-fraction stereotactic body radiation therapy case (50 Gy in 5 fractions) are presented with information regarding patient selection, target volumes, organs at risk, dose constraints, and specific considerations regarding quality assurance. Additionally, we address barriers to dose escalation and briefly discuss future directions in dose escalation for pancreatic cancer, including particle therapy and magnetic resonance guided radiation therapy. CONCLUSIONS This article on dose escalation for pancreatic cancer may help to guide academic and community based physicians and to serve as a reference for future therapeutic trials.
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Affiliation(s)
- Eugene J Koay
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | | | | | | | - Neal Rebueno
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sten Myrehaug
- Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | | | - Laura A Dawson
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Joseph M Herman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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Lee BM, Byun HK, Seong J. Significance of lymphocyte recovery from treatment-related lymphopenia in locally advanced pancreatic cancer. Radiother Oncol 2020; 151:82-87. [PMID: 32681928 DOI: 10.1016/j.radonc.2020.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE Radiation-induced lymphopenia is associated with poor prognosis in resected pancreatic cancer and locally advanced pancreatic cancer. However, whether lymphocyte recovery contributes to pancreatic cancer prognosis has not been well-investigated. MATERIALS AND METHODS We evaluated 497 locally advanced pancreatic cancer patients who underwent concurrent chemoradiotherapy (CCRT). Complete blood counts of patients were obtained before, during, and after CCRT until the 12-month follow-up visit. Patients were categorized into 3 groups according to the development of and recovery from acutte severe lymphopenia (ASL): no ASL (group A, n = 198), recovery from ASL (group B, n = 141), and no recovery from ASL (group C, n = 89). Prognostic factors of overall survival (OS) and progression-free survival (PFS) were determined using Cox regression analyses. RESULTS In groups A, B, and C, the 2-year OS rates were 40.4%, 31.9%, and 14.6%, respectively, and the 2-year PFS rates were 23.7%, 18.4%, and 10.1%, respectively. OS and PFS were comparable between Groups A and B, while group C had poor OS and PFS (p < 0.001). Recovery from ASL was associated with superior OS (HR 0.42, 95% CI: 0.32-0.55, p < 0.001) and PFS (HR 0.53, 95% CI: 0.41-0.70, p < 0.001). The baseline lymphocyte counts and target volume independently predicted development and recovery from ASL. CONCLUSION Recovery from ASL was associated with both superior OS and PFS in patients who received CCRT for locally advanced pancreatic cancer. Baseline lymphocyte counts and target volume were associated with both the development of and recovery from treatment-related ASL.
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Affiliation(s)
- Byung Min Lee
- Departments of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwa Kyung Byun
- Departments of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinsil Seong
- Departments of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Cho WK, Yu JI, Park HC, Lim DH, Kim TH, Chie EK. Impact of sarcopenia on survival of pancreatic cancer patients treated with concurrent chemoradiotherapy. TUMORI JOURNAL 2020; 107:247-253. [PMID: 32646298 DOI: 10.1177/0300891620937795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To investigate the prognostic impact of sarcopenia on the survival of patients with locally advanced pancreatic cancer (LAPC) treated with concurrent chemoradiotherapy (CCRT). METHODS We retrospectively reviewed 299 patients diagnosed with LAPC and treated with definitive CCRT from 2000 to 2015. Skeletal muscle index (SMI) was measured using computed tomography scans and sarcopenia was defined as SMI <29.6 cm2/m2 for women and <36.2 cm2/m2 for men. The significance of sarcopenia for progression-free survival (PFS) and overall survival (OS) was evaluated. RESULTS Sarcopenia was present in 29 patients (9.7%). In multivariate analysis, sarcopenia was a significant factor for PFS (p = 0.043). Although sarcopenia was not a significant factor for OS (p = 0.121) in multivariate analysis, long-term survivors were observed only in the no sarcopenia group (OS at 60 months: 9.5% vs 0%, p < 0.001). CONCLUSION In patients undergoing CCRT for LAPC, sarcopenia is an independent factor for adverse prognosis.
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Affiliation(s)
- Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Kim
- Department of Radiation Oncology, National Cancer Center, Goyang, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
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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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Wang D, Liu C, Zhou Y, Yan T, Li C, Yang Q, Xu Y, Zhao L, Pei Q, Tan F, Güngör C, Li Y. Effect of neoadjuvant radiotherapy on survival of non-metastatic pancreatic ductal adenocarcinoma: a SEER database analysis. Radiat Oncol 2020; 15:107. [PMID: 32404114 PMCID: PMC7222314 DOI: 10.1186/s13014-020-01561-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Neoadjuvant radiotherapy has been shown to improve marginal negative resection and local control of Pancreatic Ductal Adenocarcinoma (PDAC). However, whether it improves overall survival (OS) in patients with non-metastatic PDAC remains controversial. Therefore, the purpose of this study was to analyze the benefits of only surgery, neoadjuvant radiotherapy, adjuvant radiotherapy, and surgery plus chemotherapy for OS in patients with non-metastatic PDAC. METHODS PDAC diagnosed by surgical histopathology in the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2016 was selected. Kaplan-Meier analysis was used to compare the prognosis of patients with different treatments. Cox proportional risk model was used to analyze independent predictors of OS. Propensity score matching (PSM) was used to analyze the tumor prognosis of different treatment methods. RESULTS Before PSM analysis, the OS of surgery plus chemotherapy (HRs = 0.896, 95%CIs, 0.827-0.970; P = 0.007) were significantly better than the other three treatments for stage T1-3N0M0 PDAC patients. For stage T1-3N + M0 patients, adjuvant radiotherapy (HRs = 0.613, 95% CIs, 0.579-0.649; P < 0.001) had significantly better OS than surgery plus chemotherapy and neoadjuvant radiotherapy. For stage T4N0M0 patients, neoadjuvant radiotherapy (HRs = 0.482, 95% CIs, 0.347-0.670; P < 0.001) had significantly better OS than surgery plus chemotherapy and adjuvant radiotherapy. For stage T4N + M0 patients, neoadjuvant radiotherapy (HRs = 0.338, 95% CIs, 0.215-0.532; P < 0.001) had significantly longer OS than adjuvant radiotherapy and surgery plus chemotherapy. Even after PSM, Chemotherapy plus surgery was still the best treatment for T1-3N0M0 patients. Postoperative adjuvant radiotherapy had the best prognosis among T1-3N + M0 patients, and neoadjuvant radiotherapy was the best treatment for T4 patients. CONCLUSIONS For patients with non-metastatic PDAC, neoadjuvant radiotherapy, adjuvant radiotherapy and surgery plus chemotherapy were superior to only surgery in OS. For patients with stage T4 non-metastatic PDAC, neoadjuvant radiotherapy had the potential to be strongly recommended over adjuvant radiotherapy and surgery plus chemotherapy. However, neoadjuvant radiotherapy failed to benefit the survival of T1-3N0M0 stage patients, and surgery plus chemotherapy was preferred. For T1-3N + M0, neoadjuvant radiotherapy had no obvious advantage over adjuvant radiotherapy or surgery plus chemotherapy in OS, and adjuvant radiotherapy was more recommended.
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Affiliation(s)
- Dan Wang
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chongshun Liu
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Zhou
- George Washington University Hospital, Washington, USA
| | - Tingyu Yan
- Department of Ophthalmology, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Chenglong Li
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Qionghui Yang
- Department of Pediatrics, Yueqing Third People's Hospital, Yueqing, China
| | - Yang Xu
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lilan Zhao
- Department of Thoracic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Qian Pei
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Fengbo Tan
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Cenap Güngör
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yuqiang Li
- Department of General Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University, Changsha, China.
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25
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Calvo FA, Krengli M, Asencio JM, Serrano J, Poortmans P, Roeder F, Krempien R, Hensley FW. ESTRO IORT Task Force/ACROP recommendations for intraoperative radiation therapy in unresected pancreatic cancer. Radiother Oncol 2020; 148:57-64. [PMID: 32339779 DOI: 10.1016/j.radonc.2020.03.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 01/27/2023]
Abstract
Radiation therapy (RT) is a valuable component of multimodal treatment for localized pancreatic cancer. Intraoperative radiation therapy (IORT) is a very precise sub-component of RT that can intensify the irradiation effect for cancer involving an anatomically well-defined volume, generally delivered with electrons (IOERT). Unresectable disease categories benefit from dose-escalated chemoradiation strategies in the context of active systemic therapy and potential radical surgery. Prolonged preoperative treatment may act as a filter for selecting patients with occult resistant metastatic disease. Long-term survivors were observed among unresected patients treated with external beam RT and an IOERT boost (OS 6% at 3 years; 3% >5 years). Improvement of local control through higher RT doses has an impact on the survival of patients with a lower tendency towards disease spread. IOERT is a well-accepted asset in the clinical scenario (maturity and reproducibility of results, albeit of low official level of evidence) and extremely accurate in terms of dose-deposit characteristics and normal tissue sparing. It is a technique that can be integrated with systemic therapy and surgical progress. International guidelines (National Comprehensive Cancer Network or NCCN guidelines) currently recommend the use of IOERT in cases of close surgical margins and residual disease. We report the ESTRO/ACROP recommendations for performing IOERT in unresected pancreatic cancer.
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Affiliation(s)
- Felipe A Calvo
- Department of Oncology, Clínica Universidad de Navarra, Madrid, Spain; School of Medicine, Complutense University, Madrid, Spain.
| | - Marco Krengli
- Radiotherapy Unit, Department of Translation Medicine, University of Piemonte Orientale, Novara, Italy
| | - Jose M Asencio
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Facultad de Medicina, Univ. Complutense de Madrid, Spain
| | - Javier Serrano
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Facultad de Medicina, Univ. Complutense de Madrid, Spain
| | | | - Falk Roeder
- Department of Radiotherapy and Radiation Oncology, Paracelsus Medical University, Landeskrankenhaus, Salzburg, Austria
| | - Robert Krempien
- Department of Radiotherapy, Helios Hospital Berlin-Buch, Germany
| | - Frank W Hensley
- Department of Radiation Oncology, University Hospital of Heidelberg, Germany
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Jiang W, Haque W, Verma V, Butler EB, Teh BS. Neoadjuvant stereotactic body radiation therapy for nonmetastatic pancreatic adenocarcinoma. Acta Oncol 2019; 58:1259-1266. [PMID: 31237185 DOI: 10.1080/0284186x.2019.1631472] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/05/2019] [Indexed: 02/07/2023]
Abstract
Background: Neoadjuvant therapy is a strategy for resectable and borderline resectable pancreatic cancer, but a consensus approach regarding optimal management is undetermined. Neoadjuvant options include chemotherapy with/without radiotherapy. Stereotactic body radiation therapy (SBRT) is a novel radiation technique that may provide benefit over conventionally fractionated radiation therapy (CFRT) in the neoadjuvant setting. The purpose of the present study is to determine neoadjuvant treatment with SBRT to other neoadjuvant treatment options for patients with resectable pancreatic cancer. Material and methods: The National Cancer Database was queried (2004-2015) for patients with nonmetastatic pancreatic adenocarcinoma receiving neoadjuvant therapy followed by pancreatectomy. Patients were categorized based on the type of neoadjuvant treatment administered. Statistics included temporal trend assessment by annual percent change (APC), predictors for SBRT by multivariable logistic regression, Kaplan-Meier overall survival (OS) analysis without and with propensity matching, and Cox proportional hazards modeling for univariable OS analysis. Results: Of 5828 patients, 332 (5.7%), 3234 (55.5%) and 2262 (38.8%) received neoadjuvant chemo-SBRT, chemotherapy, and chemo-CFRT, respectively. SBRT utilization increased from 0% in 2004 to 9.5% in 2015, with a greater APC after 2010 (p < .001). SBRT was more likely to be utilized in patients with T3-4 and node-positive disease (p < .05 for all). The chemo-SBRT cohort was associated with a higher OS rate before and after propensity matching (p < .05 for both). The rate of R0 resection was higher in radiotherapy groups than the chemotherapy cohort (p < .001). Conclusions: Utilization of neoadjuvant SBRT for pancreatic cancer is increasing. In the neoadjuvant setting, chemo-SBRT may improve R0 resection and OS over chemotherapy and chemo-CFRT, although confirmatory prospective studies are needed for confirmation.
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Affiliation(s)
- Wei Jiang
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Shenzhen , Guangdong , China
| | - Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital , Pittsburgh , PA , USA
| | - E Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital , Houston , TX , USA
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Bertholet J, Hunt A, Dunlop A, Bird T, Mitchell RA, Oelfke U, Nill S, Aitken K. Comparison of the dose escalation potential for two hypofractionated radiotherapy regimens for locally advanced pancreatic cancer. Clin Transl Radiat Oncol 2019; 16:21-27. [PMID: 30911688 PMCID: PMC6416653 DOI: 10.1016/j.ctro.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To determine the potential for dose escalation to a biological equivalent dose BED10 ≅ 100 Gy in hypofractionated radiotherapy for locally advanced pancreatic cancer (LAPC). MATERIALS AND METHODS Ten unselected LAPC patients were retrospectively included in the study. Two fractionation regimens were compared (5 and 15 fractions). The aim was to cover 95% of the Planning Target Volume (PTV) with a BED10 = 54 Gy (base dose = 33 Gy in 5 fractions, 42.5 Gy in 15 fractions) whilst respecting organs-at-risk (OAR) constraints. Once the highest PTV coverage was achieved dose escalation to a BED10 ≅ 100 Gy (escalated dose = 50 Gy in 5 fractions, 67.5 Gy in 15 fractions) was attempted, limiting the PTV maximum dose to 130% of the escalated dose. RESULTS In 5 fractions, 95% PTV coverage by both base and escalated doses could be achieved for one patient with PTV more than 1 cm away from OAR. 95% and 90% PTV coverage by the base dose was achieved in one and two patients respectively. In all other patients, coverage even by the base dose had to be compromised to comply with OAR constraints. In 15 fractions, 95% PTV coverage by the base dose was feasible for all patients except one. Dose escalation allowed improvement in target coverage by the base dose in both fractionation regimen whilst covering a sub-volume of the PTV with a BED10 ≅ 100 Gy. Both fractionation schemes were equivalent in terms of dose escalation potential. CONCLUSION LAPC patients with OAR close to the PTV are generally not eligible for hypofractionation with dose escalation. However, this planning study shows that it is possible to cover PTV sub-volumes with a BED10 ≅ 100 Gy in addition to delivering a BED10 = 54 Gy to 90-95% of the PTV as commonly prescribed to this population. Combined with an adaptive approach, this may maximize PTV coverage by a high BED on days with favourable anatomy.
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Affiliation(s)
- Jenny Bertholet
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London SM2 5NG, UK
| | - Arabella Hunt
- The Institute of Cancer Research, London SM2 5PT, UK
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton SM2 5PT, UK
| | - Alex Dunlop
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London SM2 5NG, UK
| | - Thomas Bird
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton SM2 5PT, UK
- The Bristol Cancer Institute, Bristol BS2 8ED, UK
| | - Robert A. Mitchell
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London SM2 5NG, UK
| | - Uwe Oelfke
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London SM2 5NG, UK
| | - Simeon Nill
- Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, 15 Cotswold Road, London SM2 5NG, UK
| | - Katharine Aitken
- The Royal Marsden NHS Foundation Trust, Downs Rd, Sutton SM2 5PT, UK
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Hiroshima Y, Fukumitsu N, Saito T, Numajiri H, Murofushi KN, Ohnishi K, Nonaka T, Ishikawa H, Okumura T, Sakurai H. Concurrent chemoradiotherapy using proton beams for unresectable locally advanced pancreatic cancer. Radiother Oncol 2019; 136:37-43. [PMID: 31015127 DOI: 10.1016/j.radonc.2019.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE We investigated clinical outcomes of proton beam concurrent chemoradiotherapy (CCRT) for unresectable, locally advanced pancreatic cancer (LAPC) patients. MATERIALS AND METHODS Records from 42 unresectable LAPC patients (21 male and 21 female, 39-83 years old) with IIB/III clinical staging of 1/41 treated by proton beam CCRT were retrospectively reviewed. Twelve patients received a conventional 50 Gray equivalents (GyE) in 25 fractions protocol and 30 others received a higher dose protocol of 54.0-67.5 GyE in 25-33 fractions. Gemcitabine or S-1 (Tegafur, Gimeracil and Oteracil) was used concurrently. Toxicity, overall survival (OS) and local control (LC) were examined. RESULTS Acute adverse events of grades 1, 2, 3 and 4 were found in 4, 15, 17 and 2 patients, respectively. All grade 3 and 4 events were hematologic. Late adverse events of grades 1 and 2 were found in 3 and 2 patients, respectively. No late adverse effects of grade 3 or higher were observed. The 1-year/2-year OS rates from the start of CCRT were 77.8/50.8% with median survival time (MST) of 25.6 months. The 1-year/2-year LC rate from CCRT start was 83.3/78.9% with a median time to local recurrence of more than 36 months. Total irradiation dose was the only significant factor in univariate analyses of OS and LC (p = 0.015 and 0.023, respectively). CONCLUSION Proton beam CCRT lengthened survival periods compared to previous photon CCRT data and higher dose irradiation prolonged LC and OS for unresectable LAPC patients. Proton beam therapy is therefore safe and effective in these cases.
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Affiliation(s)
- Yuichi Hiroshima
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan.
| | - Nobuyoshi Fukumitsu
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Takashi Saito
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Haruko Numajiri
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Keiko Nemoto Murofushi
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Kayoko Ohnishi
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Tetsuo Nonaka
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Hitoshi Ishikawa
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Toshiyuki Okumura
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Hideyuki Sakurai
- Proton Medical Research Center, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575, Japan
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Venkatesulu BP, Hsieh CE, Sanders KL, Krishnan S. Recent advances in radiation therapy of pancreatic cancer. F1000Res 2018; 7:F1000 Faculty Rev-1931. [PMID: 30613390 PMCID: PMC6305239 DOI: 10.12688/f1000research.16272.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2018] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cancer has a dismal prognosis with an overall survival outcome of just 5% at five years. However, paralleling our improved understanding of the biology of pancreatic cancer, treatment paradigms have also continued to evolve with newer advances in surgical techniques, chemotherapeutic agents, radiation therapy (RT) techniques, and immunotherapy paradigms. RT dose, modality, fraction size, and sequencing are being evaluated actively, and the interplay between RT and immune effects has opened up newer avenues of research. In this review, we will emphasize recent advances in RT for pancreatic cancer, focusing on preoperative chemoradiation, RT dose escalation, sparing of the spleen to reduce lymphopenia, and combination of RT with immunotherapy.
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Affiliation(s)
- Bhanu Prasad Venkatesulu
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cheng-En Hsieh
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center-UT Health Graduate School of Biomedical Sciences, Houston, TX, USA
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Taoyuan, Taiwan
| | - Keith L Sanders
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sunil Krishnan
- Department of Experimental Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center-UT Health Graduate School of Biomedical Sciences, Houston, TX, USA
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Stefanowicz S, Stützer K, Zschaeck S, Jakobi A, Troost EGC. Comparison of different treatment planning approaches for intensity-modulated proton therapy with simultaneous integrated boost for pancreatic cancer. Radiat Oncol 2018; 13:228. [PMID: 30466468 PMCID: PMC6249773 DOI: 10.1186/s13014-018-1165-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/30/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Neoadjuvant radio(chemo)therapy of non-metastasized, borderline resectable or unresectable locally advanced pancreatic cancer is complex and prone to cause side-effects, e.g., in gastrointestinal organs. Intensity-modulated proton therapy (IMPT) enables a high conformity to the targets while simultaneously sparing the normal tissue such that dose-escalation strategies come within reach. In this in silico feasibility study, we compared four IMPT planning strategies including robust multi-field optimization (rMFO) and a simultaneous integrated boost (SIB) for dose-escalation in pancreatic cancer patients. METHODS For six pancreatic cancer patients referred for adjuvant or primary radiochemotherapy, four rMFO-IMPT-SIB treatment plans each, consisting of two or three (non-)coplanar beam arrangements, were optimized. Dose values for both targets, i.e., the elective clinical target volume [CTV, prescribed dose Dpres = 51Gy(RBE)] and the boost target [Dpres = 66Gy(RBE)], for the organs at risk as well as target conformity and homogeneity indexes, derived from the dose volume histograms, were statistically compared. RESULTS All treatment plans of each strategy fulfilled the prescribed doses to the targets (Dpres(GTV,CTV) = 100%, D95%,(GTV,CTV) ≥ 95%, D2%,(GTV,CTV) ≤ 107%). No significant differences for the conformity index were found (p > 0.05), however, treatment plans with a three non-coplanar beam strategy were most homogenous to both targets (p < 0.045). The median value of all dosimetric results of the large and small bowel as well as for the liver and the spinal cord met the dose constraints with all beam arrangements. Irrespective of the planning strategies, the dose constraint for the duodenum and stomach were not met. Using the three-beam arrangements, the dose to the left kidney could be significant decreased when compared to a two-beam strategy (p < 0.045). CONCLUSION Based on our findings we recommend a three-beam configuration with at least one non-coplanar beam for dose-escalated SIB with rMFO-IMPT in advanced pancreatic cancer patients achieving a homogeneous dose distribution in the target while simultaneously minimizing the dose to the organs at risk. Further treatment planning studies on aspects of breathing and organ motion need to be performed.
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Affiliation(s)
- Sarah Stefanowicz
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Kristin Stützer
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Sebastian Zschaeck
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Annika Jakobi
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany.,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany
| | - Esther G C Troost
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Dresden, Germany. .,Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Helmholtz-Zentrum Dresden - Rossendorf, Institute of Radiooncology - OncoRay, Dresden, Germany. .,German Cancer Consortium (DKTK), Partner Site Dresden, and German Cancer Research Center (DKFZ), Heidelberg, Germany. .,National Center for Tumor Diseases (NCT), Partner Site Dresden, Germany: German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany, and; Helmholtz Association / Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
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31
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David JM, Kim S, Placencio-Hickok VR, Torosian A, Hendifar A, Tuli R. Treatment strategies and clinical outcomes of locally advanced pancreatic cancer patients treated at high-volume facilities and academic centers. Adv Radiat Oncol 2018; 4:302-313. [PMID: 31011675 PMCID: PMC6460104 DOI: 10.1016/j.adro.2018.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 10/29/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose Locally advanced pancreatic cancer (LAPC) treatment has varying practice patterns with poor outcomes. We investigated treatment using single-agent chemotherapy and multiagent chemotherapy (MAC) with or without radiation therapy (RT) at high-volume facilities (HVFs) and academic centers (ACs). Methods and Materials The National Cancer Database was used to obtain data on 10,139 patients with LAPC. HVF was defined as the top 5% of facilities per number of patients treated at each facility. Univariate and multivariable (MVA) analysis Cox regressions were performed to identify the impact of HVF, AC, MAC, and RT on overall survival (OS). Results The median age of patients was 66 years (range, 22-90); 50.1% were male and 49.9% female. Of the patients, 46.1% received MAC, 53.8% received single-agent chemotherapy, 45.7% received RT, 54.3% did not receive RT, and 5% underwent surgical resection. The median follow-up was 48.8 months. On MVA, treatment at HVFs and ACs remained significantly associated with improved OS, with a hazard ratio (HR) of 0.84 (P < .001) and 0.94 (P = .004), respectively. The median OS for HVF treatment compared with low-volume facilities was 14.3 versus 11.2 months, respectively (P < .001). The median OS for AC treatment versus non-AC was 12.1 versus 10.8 months, respectively (P < .001). Additionally, on MVA, receipt of RT and MAC remained significantly associated with improved OS (HR: 0.76; P < .001; and HR: 0.73; P < .001, respectively). MVA for receipt of surgery showed that MAC is a significant predictor for receiving surgery (odds ratio: 1.29; P = .009). Conclusions Our results build on a growing literature supporting RT and MAC in treating LAPC. Additionally, we believe that-in the absence of prospective data-this makes a strong case for considering MAC with RT at ACs and HVFs for treating LAPC.
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Affiliation(s)
- John M. David
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sungjin Kim
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Veronica R. Placencio-Hickok
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Arman Torosian
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrew Hendifar
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Hematology and Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard Tuli
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
- Corresponding author. Department of Radiation Oncology, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048.
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Ma SJ, Prezzano KM, Hermann GM, Singh AK. Dose escalation of radiation therapy with or without induction chemotherapy for unresectable locally advanced pancreatic cancer. Radiat Oncol 2018; 13:214. [PMID: 30400962 PMCID: PMC6219058 DOI: 10.1186/s13014-018-1158-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/22/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Dose escalation of conventionally fractionated radiation therapy (CFRT) above 45-54 Gy has an unclear survival benefit. Prior National Cancer Database (NCDB) analyses have shown improved overall survival with induction chemotherapy (iC) prior to concurrent chemoradiation (CRT) in locally advanced pancreatic cancer. Our study compared dose-escalated CFRT with and without iC. METHODS The NCDB was queried for primary stage III, cT4 N0-1 M0 LAPC treated with CRT with or without iC (2004-2015). CFRT was stratified by < 55 Gy and ≥ 55 Gy. Cohort iC + CRT and CRT included those with and without iC, respectively. The primary endpoint was overall survival (OS). Kaplan-Meier analysis, Cox proportional hazards method, and propensity score matching were used. RESULTS Among 2029 patients, cohort iC + CRT had 738 patients (n = 601 for 45-55 Gy and n = 137 for ≥55 Gy) and cohort CRT had 1291 patients (n = 1066 for 45-55 Gy and n = 225 for ≥55 Gy). Median follow-up was 24.3 months and 24.6 months for cohorts iC + CRT and CRT, respectively. Dose escalation showed improved survival in the multivariable analysis in cohort iC + CRT (HR 0.77, p = 0.013) but not in cohort CRT (HR 0.91, p = 0.19). Using 2:1 propensity score matching, a total of 387 patients for cohort iC + CRT and 549 patients for cohort CRT were matched. After matching, dose escalation remained significant for improved overall survival in cohort iC + CRT (median OS 16.2 vs 15.2 months; 2-yr OS 33.4% vs 25.4%; p = 0.022) but not in cohort CRT (median OS 11.8 vs 10.6 months; 2-yr OS 13.3% vs 10.1%; p = 0.16). CONCLUSIONS Patients with locally advanced pancreatic cancer who undergo iC have improved survival with radiation dose escalation above 55 Gy. For patients without iC, there is no clear association between radiation dose escalation and survival.
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Affiliation(s)
- Sung Jun Ma
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263 USA
| | - Kavitha M. Prezzano
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263 USA
| | - Gregory M. Hermann
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263 USA
| | - Anurag K. Singh
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263 USA
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Ohira S, Yagi M, Iramina H, Karino T, Washio H, Ueda Y, Miyazaki M, Koizumi M, Teshima T. Treatment planning based on water density image generated using dual‐energy computed tomography for pancreatic cancer with contrast‐enhancing agent: Phantom and clinical study. Med Phys 2018; 45:5208-5217. [DOI: 10.1002/mp.13180] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/11/2022] Open
Affiliation(s)
- Shingo Ohira
- Department of Radiation Oncology Osaka International Cancer Institute OsakaJapan
- Department of Medical Physics and Engineering Osaka University Graduate School of Medicine SuitaJapan
| | - Masashi Yagi
- Department of Carbon Ion Radiotherapy Osaka University Graduate School of Medicine SuitaJapan
| | - Hiraku Iramina
- Department of Nuclear Engineering Graduate School of Engineering Kyoto University Kyoto Japan
- Department of Radiation Oncology Kyoto University Hospital KyotoJapan
| | - Tsukasa Karino
- Department of Radiation Oncology Osaka International Cancer Institute OsakaJapan
| | - Hayate Washio
- Department of Radiation Oncology Osaka International Cancer Institute OsakaJapan
| | - Yoshihiro Ueda
- Department of Radiation Oncology Osaka International Cancer Institute OsakaJapan
| | - Masayoshi Miyazaki
- Department of Radiation Oncology Osaka International Cancer Institute OsakaJapan
| | - Masahiko Koizumi
- Department of Medical Physics and Engineering Osaka University Graduate School of Medicine SuitaJapan
| | - Teruki Teshima
- Department of Radiation Oncology Osaka International Cancer Institute OsakaJapan
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Ohira S, Wada K, Hirata T, Kanayama N, Ikawa T, Karino T, Nitta Y, Isono M, Ueda Y, Miyazaki M, Koizumi M, Teshima T. Clinical implementation of contrast-enhanced four-dimensional dual-energy computed tomography for target delineation of pancreatic cancer. Radiother Oncol 2018; 129:105-111. [DOI: 10.1016/j.radonc.2018.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/18/2017] [Accepted: 01/20/2018] [Indexed: 12/20/2022]
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Wolfe AR, Williams TM. Altering the response to radiation: radiosensitizers and targeted therapies in pancreatic ductal adenocarcinoma: preclinical and emerging clinical evidence. ACTA ACUST UNITED AC 2018; 1. [PMID: 32656528 DOI: 10.21037/apc.2018.08.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Radiation therapy continues to have an evolving role in pancreatic ductal adenocarcinoma. While metastatic failure likely contributes to the majority of patient mortality, achieving local control through surgery and/or radiation appears to be important as certain studies suggest that mortality is contributed by local failure. Many studies support that pancreatic cancer is a relatively radiation resistant tumor type. In addition, the ability to further improve radiation through dose escalation strategies in the non-metastatic setting is hampered by closeness of normal organs, including small bowel and stomach, to the tumor. Thus subverting molecular pathways that promote radiation resistance will be critical to further success of radiation in this disease. There is a wealth of preclinical data supporting the targeting of various molecular pathways in combination with radiation therapy, including DNA repair, cell cycle checkpoint proteins, receptor tyrosine kinases, oncoproteins, stem cells, and immunomodulation. A number of clinical trials have been completed or are on-going with novel molecular inhibitors. In this review, we summarize existing preclinical and clinical molecular strategies for improving the efficacy of radiation in pancreatic cancer, and highlight recent and ongoing clinical trials combining radiation and various targeted therapies.
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Affiliation(s)
- Adam R Wolfe
- Department of Radiation Oncology, The Ohio State University Medical Center, Arthur G. James Comprehensive Cancer Center and Richard J. Solove Research Institute, Columbus, OH 43210, USA
| | - Terence M Williams
- Department of Radiation Oncology, The Ohio State University Medical Center, Arthur G. James Comprehensive Cancer Center and Richard J. Solove Research Institute, Columbus, OH 43210, USA
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Choi SH, Park SW, Seong J. A nomogram for predicting survival of patients with locally advanced pancreatic cancer treated with chemoradiotherapy. Radiother Oncol 2018; 129:340-346. [PMID: 30177371 DOI: 10.1016/j.radonc.2018.08.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/13/2018] [Accepted: 08/06/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND We developed a nomogram for predicting survival of patients with locally advanced pancreatic cancer (LAPC) after concurrent chemoradiotherapy (CRT) using 18F-flurodeoxyglucose-positron emission tomography (FDG-PET) parameters and CA 19-9 levels. METHODS Based on 426 patients with LAPC who received concurrent CRT between 2004 and 2015, we investigated significant prognostic factors for survival to build a nomogram, including the maximum standardized uptake value (SUVmax) and CA 19-9 levels. Predictive accuracy and discriminative ability were then measured. RESULTS Median progression-free survival and overall survival (OS) were 9.4 and 15.4 months, respectively, at a median 15-month follow-up. High-dose radiation (EQD2, ≥61 Gy), initial SUVmax <3.5 and CA 19-9 ≤400 U/mL, and surgical resection after CRT were significantly related to prolonged OS by multivariate analysis (p < 0.05). A nomogram model for OS was established and showed good calibration and acceptable discrimination (c-index 0.656). Using the nomogram, 3 different prognosis groups could be identified with a median OS of 25, 15, and 11 months (p < 0.001). CONCLUSION A nomogram was developed with high-dose radiation (EQD2, ≥61 Gy), initial SUVmax <3.5, CA 19-9 ≤400 U/mL, and surgical resection after CRT for patients with LAPC. This will help in clinical decision-making and in selecting patients for CRT.
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Affiliation(s)
- Seo Hee Choi
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.
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Simulation study of dosimetric effect in proton beam therapy using concomitant boost technique for unresectable pancreatic cancers. Jpn J Radiol 2018; 36:456-461. [DOI: 10.1007/s11604-018-0743-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/06/2018] [Indexed: 12/25/2022]
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Chatzizacharias NA, Tsai S, Griffin M, Tolat P, Ritch P, George B, Barnes C, Aldakkak M, Khan AH, Hall W, Erickson B, Evans DB, Christians KK. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery 2018; 163:1053-1062. [PMID: 29331400 DOI: 10.1016/j.surg.2017.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with locally advanced pancreatic cancer have historically been considered inoperable. The purpose of this report was to determine resectability rates for patients with locally advanced pancreatic cancer based on our recently described definitions of type A and type B locally advanced pancreatic cancer. METHODS An institutional prospective pancreas cancer database was queried for consecutive patients with locally advanced pancreatic cancer treated between January 2009 and June 2017. All pretreatment imaging was re-reviewed and patients were categorized as locally advanced pancreatic cancer type A or type B. Demographics, induction therapy, resection type, and outcomes were reviewed. RESULTS We identified 108 consecutive patients; 12 were excluded from analysis due to the absence of available pretreatment imaging or they had not yet completed all intended neoadjuvant therapy. Of the remaining 96 patients (45 type A, 51 type B), disease progression occurred in 19 (20%) during induction therapy and 30 (31%) were deemed inoperable at final preoperative restaging. Therefore, 47 (49%) of 96 patients were taken to surgery and 40 (42%) underwent successful resection (28 [62%] of 45 type A and 12 [24%] of 51 type B); an RO resection was achieved in 32 (80%). Metastatic disease was found intraoperatively (6 at laparoscopy, 1 at laparotomy) in 7 (15%) of 47 patients. There were no mortalities; 6 (15%) patients experienced major postoperative complications. Resected patients had a median overall survival of 38.9 months. CONCLUSION Locally advanced pancreatic cancer can be dichotomized into type A and B with distinctly different probabilities of completing all therapy to include surgery; thereby allowing goals of therapy to be established at the time of diagnosis. Multimodality therapy that includes surgery can be accomplished in selected patients with locally advanced pancreatic cancer and is associated with a median overall survival that approximates earlier stages of disease. (Surgery 2017;160:XXX-XXX.).
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Affiliation(s)
- Nikolaos A Chatzizacharias
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan Tsai
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Griffin
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Parag Tolat
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul Ritch
- Department of Medicine, Divisions of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ben George
- Department of Medicine, Divisions of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chad Barnes
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed Aldakkak
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abdul H Khan
- Department of Gastroenterology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William Hall
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Beth Erickson
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen K Christians
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA.
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Abstract
Pancreatic cancer is an aggressive malignancy with a poor long-term survival and only mild improvement in outcomes over the past 30 years. Local failure remains a problem and radiation can help improve control. The role of radiation therapy in has been controversial and is still evolving. This article reviews the trials of pancreatic cancer and radiation in adjuvant, neoadjuvant, and unresectable lesions. The article reviews the impact and outcomes of evolving radiation technology.
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40
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Dose-escalated radiotherapy for unresectable or locally recurrent pancreatic cancer: Dose volume analysis, toxicity and outcome of 28 consecutive patients. PLoS One 2017; 12:e0186341. [PMID: 29023527 PMCID: PMC5638513 DOI: 10.1371/journal.pone.0186341] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/01/2017] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The role of radiotherapy for unresectable pancreatic cancer is controversial. A benefit of additional radiotherapy is supported by some observations. A dose-effect relationship was recently found by dose escalation employing image guided and intensity modulated radiotherapy. METHODS We retrospectively evaluated 28 consecutive patients, all with history of extensive prior therapies for unresectable locally advanced/ recurrent pancreatic cancer (LAPC/LRPC). Treatment was delivered by helical tomotherapy after daily position verification with computed tomography. Dose to the planned target volume (PTV) was 51 Gy, while the dose to the macroscopic tumor was escalated by a simultaneous integrated boost to a median cumulative dose of 66 Gy (60-66 Gy). Concomitant chemotherapy consisted mainly of capecitabine (n = 23). RESULTS 10 of 28 patients presented acute toxicities > grade 2, one patient succumbed to gastrointestinal bleeding after treatment. No correlations of toxicities and dose volume histograms (DVH) of retrospectively delineated small bowel loops were observed, although average small bowel volume receiving ≥ 20 Gy was 374 ml. DVH analyses revealed a correlation of splenic parameters and acute toxicity: Vomiting, anorexia, dehydration, hematologic toxicity, fatigue, combined gastro-intestinal toxicity wit R-values between 0.392 and 0.561 (all p-values > 0.05). Only one patient developed late toxicities > grade 2. With an average follow-up time in surviving patients of 14 months median overall survival time was 19 months and median time to local recurrence 13 months. In 8 patients with available imaging of local recurrence: 5 in field recurrences, 2 marginal recurrences and one lymph node recurrence outside the high dose radiation field were observed. In univariate analysis only ΔCA-19-9 during radiotherapy was associated with local control (p = 0.029) and overall survival (p = 0.049). CONCLUSION Dose escalated normo-fractionated radiotherapy for LAPC/LRPC seems feasible and suitable to prolong local control and in consequence long-term survival. However, in-field local progression is still frequently observed and possibilities to increase the local effectiveness should be evaluated. Exposure of the spleen was predictive for acute toxicity and should be further investigated.
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