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Wolfe AR, Feng H, Zuniga O, Rodrigues H, Eldridge DE, Yang L, Shen C, Williams TM. RAS-RAF-miR-296-3p signaling axis increases Rad18 expression to augment radioresistance in pancreatic and thyroid cancers. Cancer Lett 2024; 591:216873. [PMID: 38604313 PMCID: PMC11132429 DOI: 10.1016/j.canlet.2024.216873] [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: 11/08/2023] [Revised: 03/18/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024]
Abstract
Oncogenic RAS and RAF signaling has been implicated in contributing to radioresistance in pancreatic and thyroid cancers. In this study, we sought to better clarify molecular mechanisms contributing to this effect. We discovered that miRNA 296-3p (miR-296-3p) is significantly correlated with radiosensitivity in a panel of pancreatic cancer cells, and miR-296-3p is highly expressed in normal cells, but low in cancer cell lines. Elevated expression of miR-296-3p increases radiosensitization while decreasing the expression of the DNA repair enzyme RAD18 in both pancreatic and thyroid cancer cells. RAD18 is overexpressed in both pancreatic and thyroid tumors compared to matched normal controls, and high expression of RAD18 in tumors is associated with poor prognostic features. Modulating the expression of mutant KRAS in pancreatic cancer cells or mutant BRAF in thyroid cancer cells demonstrates a tight regulation of RAD18 expression in both cancer types. Depletion of RAD18 results in DNA damage and radiation-induced cell death. Importantly, RAD18 depletion in combination with radiotherapy results in marked and sustained tumor regression in KRAS mutant pancreatic cancer orthotopic tumors and BRAF mutant thyroid heterotopic tumors. Overall, our findings identify a novel coordinated RAS/RAF-miR-296-3p-RAD18 signaling network in pancreatic and thyroid cancer cells, which leads to enhanced radioresistance.
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Affiliation(s)
- Adam R Wolfe
- Department of Radiation Oncology, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Haihua Feng
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
| | - Oscar Zuniga
- Department of Radiation Oncology, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Henrique Rodrigues
- Department of Radiation Oncology, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Daniel E Eldridge
- Department of Veterinary Medicine, The University of Arkansas for Medical Sciences, The Winthrop P. Rockefeller Cancer Institute, Little Rock, AR, USA
| | - Linlin Yang
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
| | - Changxian Shen
- Department of Radiation Oncology, City of Hope, Duarte, CA, USA
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Timmer FEF, Geboers B, Ruarus AH, Vroomen LGPH, Schouten EAC, van der Lei S, Vos DJW, Dijkstra M, Schulz HH, Bakker J, van den Bemd BAT, van den Tol PM, Puijk RS, Lissenberg-Witte BI, de Gruijl TD, de Vries JJJ, Lagerwaard FJ, Scheffer HJ, Bruynzeel AME, Meijerink MR. MRI-guided stereotactic ablative body radiotherapy versus CT-guided percutaneous irreversible electroporation for locally advanced pancreatic cancer (CROSSFIRE): a single-centre, open-label, randomised phase 2 trial. Lancet Gastroenterol Hepatol 2024; 9:448-459. [PMID: 38513683 DOI: 10.1016/s2468-1253(24)00017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma is an aggressive disease with a dismal prognosis. Stage III locally advanced pancreatic cancer is considered unresectable and current palliative chemotherapy regimens only modestly improve survival. Guidelines suggest chemoradiation or stereotactic ablative body radiotherapy (SABR) could be beneficial in certain circumstances. Other local treatments such as irreversible electroporation could enhance patient outcomes by extending survival while preserving quality of life. We aimed to compare the efficacy and safety of MRI-guided SABR versus CT-guided percutaneous irreversible electroporation following standard FOLFIRINOX chemotherapy. METHODS CROSSFIRE was an open-label, randomised phase 2 superiority trial conducted at the Amsterdam University Medical Centre (Amsterdam, Netherlands). Eligible patients were aged 18 years or older with confirmed histological and radiological stage III locally advanced pancreatic cancer. The maximum tumour diameter was 5 cm and patients had to be pretreated with three to eight cycles of FOLFIRINOX. Patients were randomly assigned (1:1) to MRI-guided SABR (five fractions of 8 Gy delivered on non-consecutive days) or CT-guided percutaneous irreversible electroporation using a computer-generated variable block randomisation model. The primary endpoint was overall survival from randomisation, assessed in the intention-to-treat population. Safety was assessed in the per-protocol population. A prespecified interim futility analysis was done after inclusion of half the original sample size, with a conditional probability of less than 0·2 resulting in halting of the study. The trial was registered at ClinicalTrials.gov, NCT02791503. FINDINGS Between May 1, 2016, and March 31, 2022, 68 patients were enrolled and randomly assigned to SABR (n=34) or irreversible electroporation (n=34), of whom 64 were treated according to protocol. Of the 68 participants, 36 (53%) were male and 32 (47%) were female, with a median age of 65 years (IQR 57-70). Median overall survival from randomisation was 16·1 months (95% CI 12·1-19·4) in the SABR group versus 12·5 months (10·9-17·0) in the irreversible electroporation group (hazard ratio [HR] 1·39 [95% CI 0·84-2·30]; p=0·21). The conditional probability to demonstrate superiority of either technique was 0·13; patient accrual was therefore stopped early for futility. 20 (63%) of 32 patients in the SABR group versus 19 (59%) of 32 patients in the irreversible electroporation group had adverse events (p=0·8) and five (16%) patients in the SABR group versus eight (25%) in the irreversible electroporation group had grade 3-5 adverse events (p=0·35). The most common grade 3-4 adverse events were cholangitis (two [6%] in the SABR group vs one [3%] in the irreversible electroporation group), abdominal pain (one [3%] vs two [6%]), and pancreatitis (none vs two [6%]). One (3%) patient in the SABR group and one (3%) in the irreversible electroporation group died from a treatment-related adverse event. INTERPRETATION CROSSFIRE did not identify a difference in overall survival or incidence of adverse events between MRI-guided SABR and CT-guided percutaneous irreversible electroporation after FOLFIRINOX. Future studies should further assess the added value of local ablative treatment over chemotherapy alone. FUNDING Adessium Foundation, AngioDynamics.
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Affiliation(s)
- Florentine E F Timmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands.
| | - Bart Geboers
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Alette H Ruarus
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Laurien G P H Vroomen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Evelien A C Schouten
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Susan van der Lei
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Danielle J W Vos
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Madelon Dijkstra
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Hannah H Schulz
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Joyce Bakker
- Department of Medical Oncology, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Bente A T van den Bemd
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | | | - Robbert S Puijk
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Radiology and Nuclear Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Birgit I Lissenberg-Witte
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Tanja D de Gruijl
- Department of Medical Oncology, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Jan J J de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Radiology and Nuclear Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Frank J Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Hester J Scheffer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands; Department of Radiology and Nuclear Medicine, Northwest Clinics, Alkmaar, Netherlands
| | - Anna M E Bruynzeel
- Department of Radiation Oncology, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Martijn R Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, Netherlands; Cancer Center Amsterdam, Amsterdam, Netherlands
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Umezawa R, Mizuma M, Nakagawa K, Yamamoto T, Takahashi N, Suzuki Y, Kishida K, Omata S, Unno M, Jingu K. Clinical impact of multimodal treatment including chemoradiotherapy, conversion surgery and postoperative chemotherapy for borderline resectable and unresectable locally advanced pancreatic cancer without disease progression after gemcitabine plus nab-paclitaxel. Pancreatology 2023; 23:650-656. [PMID: 37453848 DOI: 10.1016/j.pan.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/31/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The purpose of this study was to investigate treatment outcomes of chemoradiotherapy (CRT) using S-1 with or without conversion surgery after gemcitabine plus nab-paclitaxel (GnP) for borderline resectable (BR) and unresectable locally advanced (UR-LA) pancreatic cancer. METHODS From 2016 to 2020, patients without disease progression after GnP for BR or UR-LA pancreatic cancer underwent CRT with S-1. If distant metastasis was not detected after CRT, conversion surgery and oral administration of S-1 as postoperative adjuvant chemotherapy for at least 6 months was performed. RESULTS Forty patients were included in the present study. The median number of cycles of GnP was 6. Surgery was performed after CRT in 25 patients. The median progression-free survival (PFS) and overall survival (OS) periods from the start of radiotherapy were 24.6 and 27.4 months, respectively. The OS periods from the start of radiotherapy in patients who underwent conversion surgery and those who did not undergo conversion surgery were 41.3 and 16.8 months, respectively. The PFS periods from the start of radiotherapy in patients who underwent surgery and those who did not undergo surgery were 28.3 and 8.6 months, respectively. Patients who were able to receive S-1 after conversion surgery for more than 6 months had better OS than those who were not (p = 0.039), although there was no significant difference of PFS (p = 0.365). CONCLUSIONS In BR/UR-LA pancreatic cancer without disease progression after GnP, multimodal treatment including CRT, conversion surgery and the scheduled postoperative chemotherapy may be effective.
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Affiliation(s)
- Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kei Nakagawa
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Noriyoshi Takahashi
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yu Suzuki
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keita Kishida
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - So Omata
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Comito T, Massaro M, Teriaca MA, Franzese C, Franceschini D, Navarria P, Clerici E, Di Cristina L, Bertolini A, Tomatis S, Reggiori G, Bresolin A, Bozzarelli S, Rimassa L, Bonifacio C, Carrara S, Santoro A, Zerbi A, Scorsetti M. Can STEreotactic Body Radiation Therapy (SBRT) Improve the Prognosis of Unresectable Locally Advanced Pancreatic Cancer? Long-Term Clinical Outcomes, Toxicity and Prognostic Factors on 142 Patients (STEP Study). Curr Oncol 2023; 30:7073-7088. [PMID: 37504373 PMCID: PMC10378012 DOI: 10.3390/curroncol30070513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023] Open
Abstract
AIM The gold standard of care for pancreatic adenocarcinoma is the integrated treatment of surgery and chemotherapy (ChT), but about 50% of patients present with unresectable disease. Our study evaluated the efficacy in terms of local control, survival and safety of stereotactic body radiation therapy (SBRT) in locally advanced pancreatic cancer (LAPC). METHODS A retrospective study (STEP study) analyzed patients with LAPC treated with a dose of 45 Gy in 6 fractions. Local control (LC), distant progression free survival (DPFS), overall survival (OS) and toxicity were analyzed according to the Kaplan-Meier method. RESULTS A total of 142 patients were evaluated. Seventy-six patients (53.5%) received induction ChT before SBRT. The median follow-up was 11 months. One-, 2- and 3-year LC rate was 81.9%, 69.1% and 58.5%. Median DPFS was 6.03 months; 1- and 2-year DPFS rate was 19.9% and 4.5%. Median OS was 11.6 months and 1-, 2- and 3-year OS rates were 45.4%, 16.1%, and 9.8%. At univariate analysis, performed by the log-rank test, age < 70 years (p = 0.037), pre-SBRT ChT (p = 0.004) and post-SBRT ChT (p = 0.019) were associated with better OS. No patients experienced G3 toxicity. CONCLUSION SBRT represents an effective and safe therapeutic option in the multimodal treatment of patients with LAPC in terms of increased LC. When SBRT was sequentially integrated with ChT, the treatment proved to be promising in terms of OS as well.
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Affiliation(s)
- Tiziana Comito
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maria Massaro
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maria Ausilia Teriaca
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Pierina Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Luciana Di Cristina
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Anna Bertolini
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Bresolin
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Silvia Bozzarelli
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Cristiana Bonifacio
- Department of Radiology, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Silvia Carrara
- Department of Gastroenterology, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Armando Santoro
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Department of Pancreatic Surgery, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
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Kamel R, Dennis K, Doody J, Pantarotto J. Ablative vs. Non-Ablative Radiotherapy in Palliating Locally Advanced Pancreatic Cancer: A Single Institution Experience and a Systematic Review of the Literature. Cancers (Basel) 2023; 15:cancers15113016. [PMID: 37296977 DOI: 10.3390/cancers15113016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
We studied the dose-local control (LC) relationship in ablative vs. non-ablative radiotherapy in a non-radical treatment setting of "locally advanced pancreatic cancer (LAPC)" by comparing our patients (n = 89) treated with SBRT on the CyberKnife unit vs. conventional radiation between January 2005 and January 2021, and by reviewing the literature. A systematic search was performed leveraging Medline for references on SBRT use in pancreatic cancer without date terms or language restrictions. A total of 3702 references were identified and the search was then repeated in Embase and the Cochrane database. Ultimately, 12 studies were eligible for inclusion, which either compared SBRT to conventional radiation, or SBRT use in dose escalation for primary LAPC in a non-neoadjuvant setting. Our cohort's median overall survival was 152 days (CI 95%, 118-185); including 371 days (CI 95%, 230-511) vs. 126 days (CI 95%, 90-161) favoring SBRT, p = 0.004. The median time to local progression was 170 days (48-923) for SBRT vs. 107 days (27-489) for the non-ablative group. In our SBRT patients, no local progressions were seen with BED10 > 60 Gy. Even when palliating LAPC, SBRT should be considered as an alternative to conventional radiation, especially in patients with a low disease burden. BED10 ≥ 60-70 Gy offers better local control without increasing toxicity rates. Less local progression may provide a better quality of life to those patients who already have a short life expectancy.
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Affiliation(s)
- Randa Kamel
- Department of Radiation Oncology, UZ Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
| | - Kristopher Dennis
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
| | - Janice Doody
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
| | - Jason Pantarotto
- Department of Radiation Oncology, The Ottawa Hospital, Smyth Road 501, Ottawa, ON K1H 8L6, Canada
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Doppenberg D, Lagerwaard FJ, van Dieren S, Meijerink MR, van der Vliet JJ, Besselink MG, van Tienhoven G, Versteijne E, Slotman BJ, Wilmink JW, Kazemier G, Bruynzeel AME. Optimizing patient selection for stereotactic ablative radiotherapy in patients with locally advanced pancreatic cancer after initial chemotherapy - a single center prospective cohort. Front Oncol 2023; 13:1149961. [PMID: 37324027 PMCID: PMC10264658 DOI: 10.3389/fonc.2023.1149961] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/22/2023] [Indexed: 06/17/2023] Open
Abstract
Background The role of stereotactic ablative radiation therapy (SABR) as local treatment option after chemotherapy for locally advanced pancreatic cancer (LAPC) is evolving. However adequate patient selection criteria for SABR in patients with LAPC are lacking. Methods A prospective institutional database collected data of patients with LAPC treated with chemotherapy, mainly FOLFIRINOX, followed by SABR, which was delivered using magnetic resonance guided radiotherapy, 40 Gy in 5 fractions within two weeks. Primary endpoint was overall survival (OS). Cox regression analyses were performed to identify predictors for OS. Results Overall, 74 patients were included, median age 66 years, 45.9% had a KPS score of ≥90. Median OS was 19.6 months from diagnosis and 12.1 months from start of SABR. Local control was 90% at one year. Multivariable Cox regression analyses identified KPS ≥90, age <70, and absence of pain prior to SABR as independent favorable predictors for OS. The rate of grade ≥3 fatigue and late gastro-intestinal toxicity was 2.7%. Conclusions SABR is a well-tolerated treatment in patients with unresectable LAPC following chemotherapy, with better outcomes when applied in patients with higher performance score, age <70 years and absence of pain. Future randomized trials will have to confirm these findings.
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Affiliation(s)
- D. Doppenberg
- Amsterdam UMC, Department of Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, Netherlands
| | - F. J. Lagerwaard
- Amsterdam UMC, Department of Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - S. van Dieren
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, Netherlands
| | - M. R. Meijerink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department Intervention Radiology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J. J. van der Vliet
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department of Medical Oncology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- LAVA Therapeutics, Utrecht, Netherlands
| | - M. G. Besselink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department of Surgery, University of Amsterdam, Amsterdam, Netherlands
| | - G. van Tienhoven
- Amsterdam UMC, Department of Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - E. Versteijne
- Amsterdam UMC, Department of Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - B. J. Slotman
- Amsterdam UMC, Department of Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - J. W. Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department of Medical Oncology, University of Amsterdam, Amsterdam, Netherlands
| | - G. Kazemier
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, Department of Surgery, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - A. M. E. Bruynzeel
- Amsterdam UMC, Department of Radiation Oncology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
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7
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Jung JH, Song C, Jung IH, Ahn J, Kim B, Jung K, Lee JC, Kim J, Hwang JH. Induction FOLFIRINOX followed by stereotactic body radiation therapy in locally advanced pancreatic cancer. Front Oncol 2022; 12:1050070. [PMID: 36620548 PMCID: PMC9812488 DOI: 10.3389/fonc.2022.1050070] [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: 09/21/2022] [Accepted: 11/23/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction FOLFIRINOX (the combination of 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin) is the preferred systemic regimen for locally advanced pancreatic cancer (LAPC). Furthermore, stereotactic body radiation therapy (SBRT) is a promising treatment option for achieving local control in these patients. However, clinical outcomes in patients with LAPC treated using FOLFIRINOX followed by SBRT have not been clarified. Therefore, we aimed to evaluate clinical outcomes of induction FOLFIRINOX treatment followed by SBRT in patients with LAPC. Methods To this end, we retrospectively reviewed the medical records of patients with LAPC treated with induction FOLFIRINOX followed by SBRT in a single tertiary hospital. We evaluated overall survival (OS), progression-free survival (PFS), resection rate, SBRT-related adverse events, and prognostic factors affecting survival. Results Fifty patients were treated with induction FOLFIRINOX for a median of 8 cycles (range: 3-28), which was followed by SBRT. The median OS and PFS were 26.4 (95% confidence interval [CI]: 22.4-30.3) and 16.7 months (95% CI: 13.0-20.3), respectively. Nine patients underwent conversion surgery (eight achieved R0) and showed better OS than those who did not (not reached vs. 24.1 months, p = 0.022). During a follow-up period of 23.6 months, three cases of grade 3 gastrointestinal bleeding at the pseudoaneurysm site were noted, which were managed successfully. Analysis of the factors affecting clinical outcomes revealed that a high radiation dose (≥ 35 Gy) resulted in a higher rate of conversion surgery (25% [8/32] vs. 5.6% [1/18], respectively) and was an independent favorable prognostic factor for OS in the adjusted analysis (hazard ratio: 2.024, 95% CI: 1.042-3.930, p = 0.037). Conclusion Our findings suggest that induction FOLFIRINOX followed by SBRT in patients with LAPC results in better survival with manageable toxicities. A high total SBRT dose was associated with a high rate of conversion surgery and could afford better survival.
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Affiliation(s)
- Jae Hyup Jung
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Changhoon Song
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - In Ho Jung
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jinwoo Ahn
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Bomi Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Kwangrok Jung
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jong-Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jaihwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jin-Hyeok Hwang
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea,*Correspondence: Jin-Hyeok Hwang,
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Song JY, Chie EK, Kang SH, Jeon YJ, Ko YA, Kim DY, Kang HC. Dosimetric evaluation of magnetic resonance imaging-guided adaptive radiation therapy in pancreatic cancer by extent of re-contouring of organs-at-risk. Radiat Oncol J 2022; 40:242-250. [PMID: 36606301 PMCID: PMC9830039 DOI: 10.3857/roj.2022.00332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/14/2022] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The safety of online contouring and planning for adaptive radiotherapy is unknown. This study aimed to evaluate the dosimetric difference of the organ-at-risk (OAR) according to the extent of contouring in stereotactic magnetic resonance image-guided adaptive RT (SMART) for pancreatic cancer. MATERIALS AND METHODS We reviewed the treatment plan data used for SMART in patients with pancreatic cancer. For the online contouring and planning, OARs within 2 cm from the planning target volume (PTV) in the craniocaudal direction were re-controlled daily at the attending physician's discretion. The entire OARs were re-contoured retrospectively for data analysis. We termed the two contouring methods the Rough OAR and the Full OAR, respectively. The proportion of dose constraint violation and other dosimetric parameters was analyzed. RESULTS Nineteen patients with 94 fractions of SMART were included in the analysis. The dose constraint was violated in 10.6% and 43.6% of the fractions in Rough OAR and Full OAR methods, respectively (p = 0.075). Patients with a large tumor, a short distance from gross tumor volume (GTV) to OAR, and a tumor in the body or tail were associated with more occult dose constraint violations-large tumor (p = 0.027), short distance from GTV to OAR (p = 0.061), tumor in body or tail (p = 0.054). No dose constraint violation occurred outside 2 cm from the PTV. CONCLUSION More occult dose constraint violations can be found by the Full OAR method in patients with pancreatic cancer with some clinical factors in the online re-planning for SMART. Re-contouring all the OARs would be helpful to detect occult dose constraint violations in SMART planning. Since the dosimetric profile of SMART cannot be represented by a single fraction, patient selection for the Full OAR method should be weighted between the clinical usefulness and the time and workforce required.
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Affiliation(s)
- Jun Yeong Song
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea,Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea,Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Hee Kang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Yeon-Jun Jeon
- Seoul National University College of Medicine, Seoul, Korea
| | - Yoon-Ah Ko
- Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Yun Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea,Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Hyun-Cheol Kang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea,Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea,Correspondence: Hyun-Cheol Kang Department of Radiation Oncology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: +82-2-2072-2526 E-mail:
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9
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Lee HI, Kang HC, Chie EK. Consolidatory ablative stereotactic body radiation therapy after induction chemotherapy for unresectable pancreatic cancer: A single center experience. Front Oncol 2022; 12:974454. [PMID: 36505838 PMCID: PMC9733675 DOI: 10.3389/fonc.2022.974454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 10/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background and purpose Consolidatory radiotherapy in form of stereotactic body radiation therapy (SBRT) with an ablative dose following induction chemotherapy is emerging as a promising treatment scheme for unresectable pancreatic cancer. Outcomes of given treatment at a single center for contiguous patients with unresectable pancreatic cancer were evaluated to build the optimal treatment strategy. Materials and methods In this retrospective study, a total of 50 patients with unresectable pancreatic cancer who underwent induction chemotherapy and ablative dose SBRT were included. SBRT dose was 40-50 Gy in five fractions. Two strategies were adopted to adhere to the organs at risk (OAR) dose constraints: simultaneous integrated protection (SIP) technique and magnetic resonance (MR)-guided adaptive technique. Overall survival (OS) and local progression-free survival (LPFS) were calculated from the start date of SBRT. Results The median follow-up period for survivors was 21.1 months (range, 6.2-61.0 months). Eleven (22.0%) patients underwent resection after SBRT, which were all R0 resection. In patients with non-metastatic disease, the median OS was 26.5 months (range, 4.1-61.0 months), and the 1- and 3-year LPFS were 90.0% (95% confidence interval [CI], 72.0-96.7%) and 57.4% (95% CI, 31.7-76.4%), respectively. Patients with oligometastatic disease had inferior survival outcomes, but there was no survival difference among responders to induction chemotherapy. In the multivariable analysis, tumor size ≤4 cm, non-metastatic status, and good response to induction chemotherapy were associated with improved LPFS. In dosimetric analysis, GTV Dmin ≥50.5 Gy was the strongest prognosticator against local progression. Grade ≥3 adverse events occurred in two (4.0%) patients with non-adaptive RT, but none in patients with MR-guided adaptive RT. Conclusion Ablative dose SBRT following induction chemotherapy is an effective strategy for selected patients with unresectable pancreatic cancer. The SIP technique and MR-guided adaptive RT were attributed to minimizing the risk of adverse events. Further studies are needed to identify the best candidates for consolidatory SBRT in unresectable pancreatic cancer.
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Affiliation(s)
- Hye In Lee
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea
| | - Hyun-Cheol Kang
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea
| | - Eui Kyu Chie
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, South Korea
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, South Korea
- Institute of Radiation Medicine, Medical Research Center, Seoul National University, Seoul, South Korea
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10
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Hill CS, Rosati LM, Hu C, Fu W, Sehgal S, Hacker-Prietz A, Wolfgang CL, Weiss MJ, Burkhart RA, Hruban RH, De Jesus-Acosta A, Le DT, Zheng L, Laheru DA, He J, Narang AK, Herman JM. Neoadjuvant Stereotactic Body Radiotherapy After Upfront Chemotherapy Improves Pathologic Outcomes Compared With Chemotherapy Alone for Patients With Borderline Resectable or Locally Advanced Pancreatic Adenocarcinoma Without Increasing Perioperative Toxicity. Ann Surg Oncol 2022; 29:2456-2468. [PMID: 35129721 PMCID: PMC8933354 DOI: 10.1245/s10434-021-11202-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 11/15/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Patients with borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC) are at high risk of margin-positive resection. Neoadjuvant stereotactic body radiation therapy (SBRT) may help sterilize margins, but its additive benefit beyond neoadjuvant chemotherapy (nCT) is unclear. The authors report long-term outcomes for BRPC/LAPC patients explored after treatment with either nCT alone or nCT followed by five-fraction SBRT (nCT-SBRT). METHODS Patients with BRPC or LAPC from 2011 to 2016 who underwent resection after nCT alone or nCT-SBRT were retrospectively reviewed. Baseline characteristics were compared, and the propensity score with inverse probability weighting (IPW) was used to compare pathologic/survival outcomes. RESULTS Of 198 patients, 76 received nCT, and 122 received nCT-SBRT. The nCT-SBRT cohort had a higher proportion of LAPC (53% vs 22%; p < 0.001). The duration of nCT was longer for nCT-SBRT (4.6 vs 2.9 months; p = 0.03), but adjuvant chemotherapy was less frequently administered (53% vs 67.1%; p < 0.001). Adjuvant radiation was administered to 30% of the nCT patients. The nCT-SBRT regimen more frequently achieved negative margins (92% vs 70%; p < 0.001), negative nodes (59% vs 42%; p < 0.001), and pathologic complete response (7% vs 0%; p = 0.02). In the multivariate analysis, nCT-SBRT remained associated with R0 resection (p < 0.001). The nCT-SBRT cohort experienced no significant difference in median overall survival (OS) (22.1 vs 24.5 months), local progression-free survival (LPFS) (13.5 vs. 15.4 months), or distant metastasis-free survival (DMFS) (11.7 vs 16.3 months) after surgery. After SBRT, 1-year OS was 77.0% and 2-year OS was 50.4%. Perioperative Claven-Dindo grade 3 or greater morbidity did not differ significantly between the nCT and nCT-SBRT cohorts (p = 0.81). CONCLUSIONS Despite having more advanced disease, the nCT-SBRT cohort was still more likely to undergo an R0 resection and experienced similar survival outcomes compared with the nCT alone cohort.
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Affiliation(s)
- Colin S Hill
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Lauren M Rosati
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Chen Hu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Wei Fu
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Shuchi Sehgal
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Amy Hacker-Prietz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Matthew J Weiss
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, the Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ana De Jesus-Acosta
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dung T Le
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel A Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Sidney Kimmel Cancer Center, Baltimore, MD, USA.
| | - Joseph M Herman
- Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY, USA.
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11
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Hill C, Sehgal S, Fu W, Hu C, Reddy A, Thompson E, Hacker‐Prietz A, Le D, De Jesus‐Acosta A, Lee V, Zheng L, Laheru DA, Burns W, Weiss M, Wolfgang C, He J, Herman JM, Meyer J, Narang A. High local failure rates despite high margin-negative resection rates in a cohort of borderline resectable and locally advanced pancreatic cancer patients treated with stereotactic body radiation therapy following multi-agent chemotherapy. Cancer Med 2022; 11:1659-1668. [PMID: 35142085 PMCID: PMC8986142 DOI: 10.1002/cam4.4527] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) for patients with borderline resectable and locally advanced pancreatic adenocarcinoma (BRPC/LAPC) remains controversial. Herein, we report on surgical, pathologic, and survival outcomes in BRPC/LAPC patients treated at a high-volume institution with induction chemotherapy (CTX) followed by 5-fraction SBRT. METHODS BRPC/LAPC patients treated between 2016 and 2019 were retrospectively reviewed. Surgical and pathological outcomes were descriptively characterized. Overall survival (OS) and progression-free survival (PFS) were analyzed using Cox proportional hazard regression. Locoregional failure and distant failure were analyzed with Fine-Gray competing risk model. RESULTS Of 155 patients, 91 (59%) had LAPC and 64 (41%) had BRPC. Almost all were treated with induction multi-agent CTX with either FOLFIRINOX (75%) or gemcitabine and nab-paclitaxel (24%) for a median duration of 4.0 months (1-18 months). All received SBRT to a median dose of 33 Gy. Among 64 BRPC patients, 50 (78%) underwent resection, of whom 48 (96%) achieved margin-negative (R0) resection. Among 91 LAPC patients, 57 (63%) underwent resection, of whom 50 (88%) achieved R0 resection. Despite the high R0 rate, 33% of patients experienced locoregional failure, which was a component of 44% of all failures. After SBRT, median OS and PFS were 18.7 and 7.7 months, respectively. After SBRT, 1- and 2-year OS probabilities were 70% and 45%, whereas, from diagnosis, they were 93% and 51%. CONCLUSIONS Although a high proportion of BRPC/LAPC patients treated with induction multi-agent CTX followed by SBRT successfully achieved R0 resection, locoregional failure remained common, highlighting the need to continue to optimize radiation delivery in this context.
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Affiliation(s)
- Colin Hill
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Shuchi Sehgal
- Philadelphia College of Osteopathic MedicinePhiladelphiaPennsylvaniaUSA
| | - Wei Fu
- Department of Biostatistics and BioinformaticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Chen Hu
- Department of Biostatistics and BioinformaticsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Abhinav Reddy
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Elizabeth Thompson
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Amy Hacker‐Prietz
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Dung Le
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Ana De Jesus‐Acosta
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Valerie Lee
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Lei Zheng
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Daniel A. Laheru
- Department of PathologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - William Burns
- Department of Medical OncologyThe Sidney Kimmel Comprehensive Cancer CenterBloomberg‐Kimmel Institute for Cancer Immunotherapy at Johns HopkinsBaltimoreMarylandUSA
| | - Matthew Weiss
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Christopher Wolfgang
- Department of SurgeryZucker School of Medicine at Hofstra/NorthwellLake SuccessNew YorkUSA
| | - Jin He
- Department of Medical OncologyThe Sidney Kimmel Comprehensive Cancer CenterBloomberg‐Kimmel Institute for Cancer Immunotherapy at Johns HopkinsBaltimoreMarylandUSA
| | - Joseph M. Herman
- Department of SurgeryNew York University Grossman School of MedicineNew YorkNew YorkUSA
| | - Jeffrey Meyer
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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12
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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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13
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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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14
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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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15
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Ermongkonchai T, Khor R, Muralidharan V, Tebbutt N, Lim K, Kutaiba N, Ng SP. Stereotactic radiotherapy and the potential role of magnetic resonance-guided adaptive techniques for pancreatic cancer. World J Gastroenterol 2022; 28:745-754. [PMID: 35317275 PMCID: PMC8891728 DOI: 10.3748/wjg.v28.i7.745] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/11/2021] [Accepted: 01/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer is a malignancy with one of the poorest prognoses amongst all cancers. Patients with unresectable tumours either receive palliative care or undergo various chemoradiotherapy regimens. Conventional techniques are often associated with acute gastrointestinal toxicities, as adjacent critical structures such as the duodenum ultimately limits delivered doses. Stereotactic body radiotherapy (SBRT) is an advanced radiation technique that delivers highly ablative radiation split into several fractions, with a steep dose fall-off outside target volumes.
AIM To discuss the latest data on SBRT and whether there is a role for magnetic resonance-guided techniques in multimodal management of locally advanced, unresectable pancreatic cancer.
METHODS We conducted a search on multiple large databases to collate the latest records on radiotherapy techniques used to treat pancreatic cancer. Out of 1229 total records retrieved from our search, 36 studies were included in this review.
RESULTS Studies indicate that SBRT is associated with improved clinical efficacy and toxicity profiles compared to conventional radiotherapy techniques. Further dose escalation to the tumour with SBRT is limited by the poor soft-tissue visualisation of computed tomography imaging during radiation planning and treatment delivery. Magnetic resonance-guided techniques have been introduced to improve imaging quality, enabling treatment plan adaptation and re-optimisation before delivering each fraction.
CONCLUSION Therefore, SBRT may lead to improved survival outcomes and safer toxicity profiles compared to conventional techniques, and the addition of magnetic resonance-guided techniques potentially allows dose escalation and conversion of unresectable tumours to operable cases.
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Affiliation(s)
- Tai Ermongkonchai
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Richard Khor
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | | | - Niall Tebbutt
- Department of Medical Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
| | - Kelvin Lim
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Numan Kutaiba
- Department of Diagnostic Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Centre at Austin Health, Heidelberg 3084, Victoria, Australia
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16
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Tyagi N, Liang J, Burleson S, Subashi E, Godoy Scripes P, Tringale KR, Romesser PB, Reyngold M, Crane CH. Feasibility of ablative stereotactic body radiation therapy of pancreas cancer patients on a 1.5 Tesla magnetic resonance-linac system using abdominal compression. Phys Imaging Radiat Oncol 2021; 19:53-59. [PMID: 34307919 PMCID: PMC8295846 DOI: 10.1016/j.phro.2021.07.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND PURPOSE Stereotactic body radiation therapy delivered using MR-guided radiotherapy (MRgRT) and automatic breathold gating has shown to improve overall survival for locally advanced pancreatic cancer (LAPC) patients. The goal of our study was to evaluate feasibility of treating LAPC patients using abdominal compression (AC) and impact of potential intrafraction motion on planned dose on a 1.5T MR-linac. METHODS & MATERIALS Ten LAPC patients were treated with MRgRT to 50 Gy in 5 fractions with daily online plan adaptation and AC. Three orthogonal plane cine MRI were acquired to assess stability of AC pressure in minimizing tumor motion. Three sets of T2w MR scans, pre-treatment (MRIpre), verification (MRIver) and post-treatment (MRIpost) MRI, were acquired for every fraction. A total of 150 MRIs and doses were evaluated. Impact of intrafraction organ motion was evaluated by propagating pre-treatment plan and structures to MRIver and MRIpost, editing contours and recalculating doses. Gross tumor volume (GTV) coverage and organs-at-risk (OARs) doses were evaluated on MRIver and MRIpost. RESULTS Median total treatment time was 75.5 (49-132) minutes. Median tumor motion in AC for all fractions was 1.7 (0.7-7), 2.1 (0.6-6.3) and 4.1 (1.4-10.0) mm in anterior-posterior, left-right and superior-inferior direction. Median GTV V50Gy was 78.7%. Median D5cm3 stomach_duodenum was 24.2 (18.4-29.3) Gy on MRIver and 24.2 (18.3-30.5) Gy on MRIpost. Median D5cm3 small bowel was 24.3 (18.2-32.8) Gy on MRIver and 24.4 (16.0-33.6) Gy on MRIpost. CONCLUSION Dose-volume constraints for OARs were exceeded for some fractions on MRIver and MRIpost. Longer follow up is needed to see the dosimetric impact of intrafraction motion on gastrointestinal toxicity.
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Affiliation(s)
- Neelam Tyagi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Jiayi Liang
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Sarah Burleson
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Ergys Subashi
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Paola Godoy Scripes
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Kathryn R. Tringale
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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17
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Zhang B, Zhou F, Hong J, Ng DM, Yang T, Zhou X, Jin J, Zhou F, Chen P, Xu Y. The role of FOLFIRINOX in metastatic pancreatic cancer: a meta-analysis. World J Surg Oncol 2021; 19:182. [PMID: 34154596 PMCID: PMC8218408 DOI: 10.1186/s12957-021-02291-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/04/2021] [Indexed: 12/20/2022] Open
Abstract
Background The prognosis of pancreatic cancer (PC) is extremely poor, and most patients with metastatic PC still receive palliative care. Here, we report the efficacy and safety of FOLFIRINOX (oxaliplatin, irinotecan, leucovorin, 5-fluorouracil) in the treatment of metastatic PC. Methods We searched PubMed, Web of Science, EBSCO, and Cochrane library databases for articles that described efficacy and safety of FOLFIRINOX in patients with metastatic PC, from January 1996 to July 2020. The primary outcomes targeted included overall survival (OS) and progression-free survival (PFS). Results We found that FOLFIRINOX could directly improve OS rate of patients with metastatic PC (HR 0.76, 95% Cl 0.67–0.86, p<0.001) but had no benefit on PFS. Results from subgroup analyses showed that FOLFIRINOX had superior benefits than monochemotherapy (HR 0.59, 95% Cl 0.52–0.67, p<0.001), followed by FOLFIRINOX versus combination chemotherapy (HR 0.76, 95% Cl 0.61–0.95, p<0.001). The result of FOLFIRINOX versus nab-paclitaxel + gemcitabine had no benefit (HR 0.91, 95% Cl 0.82–1.02, p>0.05). The main adverse events (AEs) targeted hematological toxicity and the gastrointestinal system, and included febrile neutropenia, a reduction in white blood cells and appetite, as well as diarrhea. Conclusion These findings indicated that FOLFIRINOX has potential benefits for the prognosis of patients with metastatic PC. Furthermore, there is no difference between the regimen of FOLFIRINOX and nab-paclitaxel + gemcitabine in this study. The application of FOLFIRINOX should be according to the actual situation of the patients and the experience of the doctors. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02291-6.
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Affiliation(s)
- Beilei Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Fengyan Zhou
- Emergency Medical Center, Ningbo Yinzhou No 2 Hospital, Ningbo, Zhejiang, China
| | - Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Derry Minyao Ng
- Medical College of Ningbo University, Ningbo, Zhejiang, China
| | - Tong Yang
- Department of Tumor HIFU Therapy, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Xinyu Zhou
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jieyin Jin
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Feifei Zhou
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Ping Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China
| | - Yunbao Xu
- Department of Radiotherapy and Chemotherapy, Hwamei Hospital, University of Chinese Academy of Sciences, Northwest Street 41, Haishu District, Ningbo, 315010, Zhejiang, China.
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18
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Rossi G, Simoni N, Paiella S, Rossi R, Venezia M, Micera R, Malleo G, Salvia R, Giuliani T, Di Gioia A, Auriemma A, Milella M, Guariglia S, Cavedon C, Bassi C, Mazzarotto R. Risk Adapted Ablative Radiotherapy After Intensive Chemotherapy for Locally Advanced Pancreatic Cancer. Front Oncol 2021; 11:662205. [PMID: 33959509 PMCID: PMC8093383 DOI: 10.3389/fonc.2021.662205] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/16/2021] [Indexed: 01/05/2023] Open
Abstract
Background and Objective To assess the efficacy of a Risk-Adapted Ablative Radiotherapy (RAdAR) approach, after intensive induction chemotherapy, in patients with locally advanced pancreatic cancer (LAPC). Material and Methods Patients with LAPC who received RAdAR following induction chemotherapy from January 2017 to December 2019 were included in this observational study. The RAdAR approach consisted of an anatomy- and simultaneous integrated boost (SIB)-based dose prescription strategy. RAdAR was delivered with stereotactic ablative radiation therapy (SAbR), administering 30 Gy in 5 fractions to the tumor volume (PTVt) and 50 Gy SIB (BED10 100 Gy) to the vascular involvement, or with (hypo-)fractionated ablative radiotherapy (HART) prescribing 50.4 Gy in 28 fractions to the PTVt, with a vascular SIB of 78.4 Gy (BED10 100 Gy). Primary end points were freedom from local progression (FFLP), overall survival (OS), and progression-free survival (PFS). Results Sixty-four LAPC patients were included. Induction chemotherapy consisted of gemcitabine/nab-paclitaxel in 60.9% and FOLFIRINOX in 39.1% of cases. SAbR was used in 52 (81.2%) patients, and HART in 12 (18.8%). After RAdAR, surgery was performed in 17 (26.6%) patients. Median follow-up was 16.1 months. Overall local control (LC) rate was 78.1%, with no difference between resected and non-resected patients (2-year FFLP 75.3% vs 56.4%; p = 0.112). Median OS and PFS were 29.7 months and 8.7 months, respectively, for the entire cohort. Resected patients had a better median OS (not reached versus 26.1 months; p = 0.0001) and PFS (19 versus 5.6 months; p < 0.0001) compared to non-resected patients. In non-resected patients, no significant difference was found between SAbR and HART for median FFLP (28.1 versus 18.5 months; p = 0.614), OS (27.4 versus 25.3 months; p = 0.624), and PFS (5.7 versus 4.3 months; p = 0.486). One patient (1.6%) experienced acute grade 4 gastro-intestinal bleeding. No other acute or late grade ≥ 3 toxicities were observed. Conclusions The RAdAR approach, following intensive induction chemotherapy, is an effective radiation treatment strategy for selected LAPC patients, representing a promising therapeutic option in a multimodality treatment regimen.
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Affiliation(s)
- Gabriella Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Nicola Simoni
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Rossi
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Martina Venezia
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Renato Micera
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Giuliani
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Anthony Di Gioia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandra Auriemma
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Michele Milella
- Department of Oncology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefania Guariglia
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Carlo Cavedon
- Department of Medical Physics, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Renzo Mazzarotto
- Department of Radiation Oncology, University of Verona Hospital Trust, Verona, Italy
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