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Steinvoort-Draat IN, Otto-Vollaard L, Quint S, Tims JL, de Pree IMN, Nuyttens JJ. Palliative radiotherapy: New prognostic factors for patients with bone metastasis. Cancer Radiother 2024; 28:236-241. [PMID: 38871605 DOI: 10.1016/j.canrad.2023.09.003] [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: 02/24/2023] [Revised: 09/12/2023] [Accepted: 09/25/2023] [Indexed: 06/15/2024]
Abstract
PURPOSE Many cancer patients develop bone metastases, however the prognosis of overall survival differs. To provide an optimal treatment for these patients, especially towards the end of life, a reliable prediction of survival is needed. The goal of this study was to find new clinical factors in relation to overall survival. MATERIALS AND METHODS Prospectively 22 clinical factors were collected from 734 patients. The Kaplan-Meier and Cox regression models were used. RESULTS Most patients were diagnosed with lung cancer (29%), followed by prostate (19.8%) and breast cancer (14.7%). Median overall survival was 6.4months. Fourteen clinical factors showed significance in the univariate analyses. In the multivariate analyses 6 factors were found to be significant for the overall survival: Karnofsky performance status, primary tumor, gender, total organs affected, morphine use and systemic treatment options after radiotherapy. CONCLUSION Morphine use and systemic treatment options after radiotherapy, Karnofsky performance status, primary tumor, gender and total organs affected are strong prediction factors on overall survival after palliative radiotherapy in patients with bone metastasis. These factors are easily applicable in the clinic.
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Affiliation(s)
- I N Steinvoort-Draat
- Department of radiotherapy, Erasmus MC Cancer Institute, Postbus 2040, 3000 CA Rotterdam, The Netherlands.
| | - L Otto-Vollaard
- Department of radiotherapy, Erasmus MC Cancer Institute, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - S Quint
- Department of radiotherapy, Erasmus MC Cancer Institute, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - J L Tims
- Department of radiotherapy, Erasmus MC Cancer Institute, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - I M N de Pree
- Department of radiotherapy, Erasmus MC Cancer Institute, Postbus 2040, 3000 CA Rotterdam, The Netherlands
| | - J J Nuyttens
- Department of radiotherapy, Erasmus MC Cancer Institute, Postbus 2040, 3000 CA Rotterdam, The Netherlands
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2
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Kaganda Bomboka V, Galietta E, Donati CM, Cellini F, Rossi R, Buwenge M, Wondemagegnehu T, Deressa BT, Uddin AK, Sumon MA, Vadalà M, Maltoni M, Morganti AG. Assessing the effectiveness of palliative radiotherapy for painful bone metastases in low- and middle-income countries: A systematic review. J Med Imaging Radiat Oncol 2024; 68:495-504. [PMID: 38577713 DOI: 10.1111/1754-9485.13647] [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: 11/05/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
Palliative radiotherapy (RT) effectively relieves pain in patients with bone metastases (BMs). Furthermore, several clinical trials, in most cases conducted in high-income countries (HICs), proved that single-fraction RT is equally effective compared to multi-fractionated RT. However, the evidence is scarce regarding low/middle-income countries (LMICs), where the diagnosis of BMs could be later and RT techniques less advanced. Therefore, we conducted a systematic literature review to evaluate the efficacy of palliative RT of BMs in the LMIC setting. A literature search was performed independently by two authors on the PubMed, Cochrane and Scopus databases. Overall, 333 records were screened and after the selection process, 11 papers were included in the analysis. Complete pain response rates ranged from 11.5% to 37.1% (median: 22%) for single-fraction RT and from 0% to 35.1% (median: 19%) for multi-fractionated RT. Partial pain response rates ranged from 23.1% to 76.9% (median: 53.8%) for single fraction RT and from 23.8% to 84.6% (median: 65%) for multi-fractionated RT. Four randomized trials compared single-fraction RT with multiple-fraction RT and none of them showed significant differences in terms of pain relief. Our analysis showed that pain response rates after palliative RT recorded in LMIC are like those reported in studies performed in HIC. Even in this setting, RT in single fraction shows comparable pain response rates to multifractional RT.
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Affiliation(s)
- Von Kaganda Bomboka
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Bologna University, Bologna, Italy
| | - Erika Galietta
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Bologna University, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Costanza Maria Donati
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Bologna University, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Cellini
- Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC di Radioterapia, Roma, Italy
- Istituto di Radiologia, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Romina Rossi
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Milly Buwenge
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Bologna University, Bologna, Italy
| | - Tigeneh Wondemagegnehu
- Radiotherapy Department, Tikur Anbessa Specialized Hospital, Department of Clinical Oncology, College of Medicine and Health Sciences, University of Gondar, Addis Ababa, Ethiopia
| | | | - Afm Kamal Uddin
- Department of Radiation Oncology, United Hospital Limited, Dhaka, Bangladesh
| | - Mostafa A Sumon
- Radiation Oncology, Kurmitola General Hospital, Dhaka, Bangladesh
| | - Maria Vadalà
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Maltoni
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Bologna University, Bologna, Italy
- Medical Oncology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessio Giuseppe Morganti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - Bologna University, Bologna, Italy
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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3
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Alcorn S, Cortés ÁA, Bradfield L, Brennan M, Dennis K, Diaz DA, Doung YC, Elmore S, Hertan L, Johnstone C, Jones J, Larrier N, Lo SS, Nguyen QN, Tseng YD, Yerramilli D, Zaky S, Balboni T. External Beam Radiation Therapy for Palliation of Symptomatic Bone Metastases: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024:S1879-8500(24)00099-7. [PMID: 38788923 DOI: 10.1016/j.prro.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE This guideline provides evidence-based recommendations for palliative external beam radiation therapy (RT) in symptomatic bone metastases. METHODS The ASTRO convened a task force to address 5 key questions regarding palliative RT in symptomatic bone metastases. Based on a systematic review by the Agency for Health Research and Quality, recommendations using predefined consensus-building methodology were established; evidence quality and recommendation strength were also assessed. RESULTS For palliative RT for symptomatic bone metastases, RT is recommended for managing pain from bone metastases and spine metastases with or without spinal cord or cauda equina compression. Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone. Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression. Patients with nonspine bone metastases requiring surgery are recommended postoperative RT. Symptomatic bone metastases treated with conventional RT are recommended 800 cGy in 1 fraction (800 cGy/1 fx), 2000 cGy/5 fx, 2400 cGy/6 fx, or 3000 cGy/10 fx. Spinal cord or cauda equina compression in patients who are ineligible for surgery and receiving conventional RT are recommended 800 cGy/1 fx, 1600 cGy/2 fx, 2000 cGy/5 fx, or 3000 cGy/10 fx. Symptomatic bone metastases in selected patients with good performance status without surgery or neurologic symptoms/signs are conditionally recommended stereotactic body RT over conventional palliative RT. Spine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, 2400 cGy/6 fx, or 2000 cGy/8 fx; nonspine bone metastases reirradiated with conventional RT are recommended 800 cGy/1 fx, 2000 cGy/5 fx, or 2400 cGy/6 fx. Determination of an optimal RT approach/regimen requires whole person assessment, including prognosis, previous RT dose if applicable, risks to normal tissues, quality of life, cost implications, and patient goals and values. Relatedly, for patient-centered optimization of treatment-related toxicities and quality of life, shared decision making is recommended. CONCLUSIONS Based on published data, the ASTRO task force's recommendations inform best clinical practices on palliative RT for symptomatic bone metastases.
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Affiliation(s)
- Sara Alcorn
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota.
| | - Ángel Artal Cortés
- Department of Medical Oncology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | | | - Kristopher Dennis
- Division of Radiation Oncology, Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Dayssy A Diaz
- Department of Radiation Oncology, Ohio State University, Columbus, Ohio
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, Oregon
| | - Shekinah Elmore
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Lauren Hertan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Candice Johnstone
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joshua Jones
- Department of Radiation Oncology, Rochester Regional Health, Rochester, New York
| | - Nicole Larrier
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Quynh-Nhu Nguyen
- Department of Radiation Oncology, University of Texas - MD Anderson Cancer Center, Houston, Texas
| | - Yolanda D Tseng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Divya Yerramilli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sandra Zaky
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Tracy Balboni
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
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4
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Gillespie EF, Santos PMG, Curry M, Salz T, Chakraborty N, Caron M, Fuchs HE, Ledesma Vicioso N, Mathis N, Kumar R, O’Brien C, Patel S, Guttmann DM, Ostroff JS, Salner AL, Panoff JE, McIntosh AF, Pfister DG, Vaynrub M, Yang JT, Lipitz-Snyderman A. Implementation Strategies to Promote Short-Course Radiation for Bone Metastases. JAMA Netw Open 2024; 7:e2411717. [PMID: 38787561 PMCID: PMC11127116 DOI: 10.1001/jamanetworkopen.2024.11717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/11/2024] [Indexed: 05/25/2024] Open
Abstract
Importance For patients with nonspine bone metastases, short-course radiotherapy (RT) can reduce patient burden without sacrificing clinical benefit. However, there is great variation in uptake of short-course RT across practice settings. Objective To evaluate whether a set of 3 implementation strategies facilitates increased adoption of a consensus recommendation to treat nonspine bone metastases with short-course RT (ie, ≤5 fractions). Design, Setting, and Participants This prospective, stepped-wedge, cluster randomized quality improvement study was conducted at 3 community-based cancer centers within an existing academic-community partnership. Rollout was initiated in 3-month increments between October 2021 and May 2022. Participants included treating physicians and patients receiving RT for nonspine bone metastases. Data analysis was performed from October 2022 to May 2023. Exposures Three implementation strategies-(1) dissemination of published consensus guidelines, (2) personalized audit-and-feedback reports, and (3) an email-based electronic consultation platform (eConsult)-were rolled out to physicians. Main Outcomes and Measures The primary outcome was adherence to the consensus recommendation of short-course RT for nonspine bone metastases. Mixed-effects logistic regression at the bone metastasis level was used to model associations between the exposure of physicians to the set of strategies (preimplementation vs postimplementation) and short-course RT, while accounting for patient and physician characteristics and calendar time, with a random effect for physician. Physician surveys were administered before implementation and after implementation to assess feasibility, acceptability, and appropriateness of each strategy. Results Forty-five physicians treated 714 patients (median [IQR] age at treatment start, 67 [59-75] years; 343 women [48%]) with 838 unique nonspine bone metastases during the study period. Implementing the set of strategies was not associated with use of short-course RT (odds ratio, 0.78; 95% CI, 0.45-1.34; P = .40), with unadjusted adherence rates of 53% (444 lesions) preimplementation vs 56% (469 lesions) postimplementation; however, the adjusted odds of adherence increased with calendar time (odds ratio, 1.68; 95% CI, 1.20-2.36; P = .003). All 3 implementation strategies were perceived as being feasible, acceptable, and appropriate; only the perception of audit-and-feedback appropriateness changed before vs after implementation (19 of 29 physicians [66%] vs 27 of 30 physicians [90%]; P = .03, Fisher exact test), with 20 physicians (67%) preferring reports quarterly. Conclusions and Relevance In this quality improvement study, a multicomponent set of implementation strategies was not associated with increased use of short-course RT within an academic-community partnership. However, practice improved with time, perhaps owing to secular trends or physician awareness of the study. Audit-and-feedback was more appropriate than anticipated. Findings support the need to investigate optimal approaches for promoting evidence-based radiation practice across settings.
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Affiliation(s)
- Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, University of Washington School of Medicine, Fred Hutchinson Cancer Center, Seattle
| | - Patricia Mae G. Santos
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Curry
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Talya Salz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nirjhar Chakraborty
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael Caron
- Department of Strategic Partnerships, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hannah E. Fuchs
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nahomy Ledesma Vicioso
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Noah Mathis
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rahul Kumar
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami
| | - Connor O’Brien
- Department of Radiation Oncology, Hartford HealthCare Cancer Institute, Hartford, Connecticut
| | - Shivani Patel
- Department of Radiation Oncology, Lehigh Valley Cancer Institute, Allentown, Pennsylvania
| | - David M. Guttmann
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jamie S. Ostroff
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew L. Salner
- Department of Radiation Oncology, Hartford HealthCare Cancer Institute, Hartford, Connecticut
| | - Joseph E. Panoff
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami
| | - Alyson F. McIntosh
- Department of Radiation Oncology, Lehigh Valley Cancer Institute, Allentown, Pennsylvania
| | - David G. Pfister
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Max Vaynrub
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan T. Yang
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Radiation Oncology, NYU School of Medicine, New York, New York
| | - Allison Lipitz-Snyderman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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5
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Ben-David MA, Schwartz I, Eshed I, Levanon K. Gemcitabine-Induced Myonecrosis Following Hypofractionated Radiation. Cureus 2024; 16:e58591. [PMID: 38765409 PMCID: PMC11102761 DOI: 10.7759/cureus.58591] [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] [Accepted: 04/17/2024] [Indexed: 05/22/2024] Open
Abstract
Palliative radiation is often used to abate pain and prevent bone fractures in patients with metastatic cancer. Hypofractionation, meaning delivery of larger doses of radiation in each treatment session (fraction), has become the standard of care in most cases. It not only reduces the burden on the medical system and facilitates the relief of symptoms but also enables the maintenance of the continuity of systemic therapy. Radiation recall phenomenon (RRP) is an acute inflammatory reaction in previously irradiated tissues that is provoked by chemotherapeutic drug administration. The incidence, severity, and prognosis of RRP following hypofractionated radiation therapy have not been studied. The symptoms of RRP depend on the radiation field, with the greatest concern associated with mucosal and dermal damage, though other symptoms have also been reported. Here, we describe a case of a 41-year-old woman with metastatic breast cancer (hormone receptor-positive, HER2/neu negative), who received palliative radiation to four other fields along the course of her disease, before her presentation with isolated myonecrosis of the thigh muscles. This RRP occurred four months following the last of two fractions of 8 Gy radiation to this region, given three months apart, and after six courses of cisplatin + gemcitabine. The symptoms improved with cessation of gemcitabine and prolonged administration of non-steroidal anti-inflammatory medications.
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Affiliation(s)
- Merav A Ben-David
- Department of Oncology, Assuta Medical Center, Tel Aviv, ISR
- Faculty of Health Sciences, Ben Gurion University, Beer-Sheva, ISR
| | - Ignat Schwartz
- Department of Pathology, Sheba Medical Center, Ramat Gan, ISR
| | - Iris Eshed
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, ISR
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, ISR
| | - Keren Levanon
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, ISR
- The Jusidman Cancer Center, Sheba Medical Center, Ramat Gan, ISR
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6
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Maemoto H, Kushi K, Owan I, Ariga T, Heianna J, Nishie A. Deterioration of Performance Status during Palliative Radiotherapy Suggests a Significant Short Survival Duration: Indicating the Necessities for Considering Radiotherapy Discontinuation. Curr Oncol 2024; 31:1752-1761. [PMID: 38668036 PMCID: PMC11049355 DOI: 10.3390/curroncol31040133] [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: 02/20/2024] [Revised: 03/11/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Discontinuation of palliative radiotherapy due to a patient's declining general condition poses a clinical dilemma for palliative care physicians. This study aimed to investigate the survival duration of patients whose performance status (PS) deteriorated during palliative radiotherapy and inform decisions regarding early treatment discontinuation. We retrospectively analyzed data from patients referred from our institute's palliative care department who underwent ≥10 fractions of palliative radiotherapy between March 2017 and December 2021. PS was assessed using the Eastern Cooperative Oncology Group (ECOG) scale. Survival duration was calculated from the final day of palliative radiotherapy to death using the Kaplan-Meier method. A total of 35 patients underwent palliative radiotherapy. Seven (20%) experienced deterioration in ECOG PS during treatment. Their median survival duration was significantly shorter at 22 days (95% confidence interval: 1-94 days) compared to 125 days (95% confidence interval: 82-150 days) for the 28 patients whose PS remained stable (p = 0.0007). Deterioration in ECOG PS during palliative radiotherapy signifies a markedly shorter survival duration. Careful assessment of a patient's condition throughout treatment is crucial, and early discontinuation should be considered if their general health worsens rather than strictly adhering to the initial schedule.
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Affiliation(s)
- Hitoshi Maemoto
- Division of Radiation Oncology, NHO Okinawa Hospital, Okinawa 901-2214, Japan
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
| | - Kazuaki Kushi
- Division of Palliative Care, NHO Okinawa Hospital, Okinawa 901-2214, Japan
| | - Isoko Owan
- Division of Pulmonary Medicine, NHO Okinawa Hospital, Okinawa 901-2214, Japan;
| | - Takuro Ariga
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
- Health Information Management Center, University of the Ryukyus Hospital, Okinawa 903-0213, Japan
| | - Joichi Heianna
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
| | - Akihiro Nishie
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa 903-0213, Japan; (T.A.); (J.H.); (A.N.)
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7
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Daugherty EC, Zhang Y, Xiao Z, Mascia AE, Sertorio M, Woo J, McCann C, Russell KJ, Sharma RA, Khuntia D, Bradley JD, Simone CB, Breneman JC, Perentesis JP. FLASH radiotherapy for the treatment of symptomatic bone metastases in the thorax (FAST-02): protocol for a prospective study of a novel radiotherapy approach. Radiat Oncol 2024; 19:34. [PMID: 38475815 PMCID: PMC10935811 DOI: 10.1186/s13014-024-02419-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND FLASH therapy is a treatment technique in which radiation is delivered at ultra-high dose rates (≥ 40 Gy/s). The first-in-human FAST-01 clinical trial demonstrated the clinical feasibility of proton FLASH in the treatment of extremity bone metastases. The objectives of this investigation are to assess the toxicities of treatment and pain relief in study participants with painful thoracic bone metastases treated with FLASH radiotherapy, as well as workflow metrics in a clinical setting. METHODS This single-arm clinical trial is being conducted under an FDA investigational device exemption (IDE) approved for 10 patients with 1-3 painful bone metastases in the thorax, excluding bone metastases in the spine. Treatment will be 8 Gy in a single fraction administered at ≥ 40 Gy/s on a FLASH-enabled proton therapy system delivering a single transmission proton beam. Primary study endpoints are efficacy (pain relief) and safety. Patient questionnaires evaluating pain flare at the treatment site will be completed for 10 consecutive days post-RT. Pain response and adverse events (AEs) will be evaluated on the day of treatment and on day 7, day 15, months 1, 2, 3, 6, 9, and 12, and every 6 months thereafter. The outcomes for clinical workflow feasibility are the occurrence of any device issues as well as time on the treatment table. DISCUSSION This prospective clinical trial will provide clinical data for evaluating the efficacy and safety of proton FLASH for palliation of bony metastases in the thorax. Positive findings will support the further exploration of FLASH radiation for other clinical indications including patient populations treated with curative intent. REGISTRATION ClinicalTrials.gov NCT05524064.
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Affiliation(s)
- E C Daugherty
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Y Zhang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - Z Xiao
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - A E Mascia
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - M Sertorio
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - J Woo
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - C McCann
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - K J Russell
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - R A Sharma
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - D Khuntia
- Varian, a Siemens Healthineers Company, Palo Alto, USA
| | - J D Bradley
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - C B Simone
- Department of Radiation Oncology, New York Proton Center , New York, NY, USA
| | - J C Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - J P Perentesis
- Cancer and Blood Disease Institute , Cincinnati Children's Hospital , Cincinnati, OH, USA.
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8
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Sacino AN, Chen H, Sahgal A, Bettegowda C, Rhines LD, Maralani P, Redmond KJ. Stereotactic body radiation therapy for spinal metastases: A new standard of care. Neuro Oncol 2024; 26:S76-S87. [PMID: 38437670 PMCID: PMC10911798 DOI: 10.1093/neuonc/noad225] [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] [Indexed: 03/06/2024] Open
Abstract
Advancements in systemic therapies for patients with metastatic cancer have improved overall survival and, hence, the number of patients living with spinal metastases. As a result, the need for more versatile and personalized treatments for spinal metastases to optimize long-term pain and local control has become increasingly important. Stereotactic body radiation therapy (SBRT) has been developed to meet this need by providing precise and conformal delivery of ablative high-dose-per-fraction radiation in few fractions while minimizing risk of toxicity. Additionally, advances in minimally invasive surgical techniques have also greatly improved care for patients with epidural disease and/or unstable spines, which may then be combined with SBRT for durable local control. In this review, we highlight the indications and controversies of SBRT along with new surgical techniques for the treatment of spinal metastases.
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Affiliation(s)
- Amanda N Sacino
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Chetan Bettegowda
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Laurence D Rhines
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - Pejman Maralani
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kristin J Redmond
- Department of Radiation and Molecular Oncology, John Hopkins University, Baltimore, Maryland, USA
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9
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Bindels BJJ, Mercier C, Gal R, Verlaan JJ, Verhoeff JJC, Dirix P, Ost P, Kasperts N, van der Linden YM, Verkooijen HM, van der Velden JM. Stereotactic Body and Conventional Radiotherapy for Painful Bone Metastases: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2355409. [PMID: 38345820 PMCID: PMC10862159 DOI: 10.1001/jamanetworkopen.2023.55409] [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: 09/29/2023] [Accepted: 12/12/2023] [Indexed: 02/15/2024] Open
Abstract
Importance Conventional external beam radiotherapy (cEBRT) and stereotactic body radiotherapy (SBRT) are commonly used treatment options for relieving metastatic bone pain. The effectiveness of SBRT compared with cEBRT in pain relief has been a subject of debate, and conflicting results have been reported. Objective To compare the effectiveness associated with SBRT vs cEBRT for relieving metastatic bone pain. Data Sources A structured search was performed in the PubMed, Embase, and Cochrane databases on June 5, 2023. Additionally, results were added from a new randomized clinical trial (RCT) and additional unpublished data from an already published RCT. Study Selection Comparative studies reporting pain response after SBRT vs cEBRT in patients with painful bone metastases. Data Extraction and Synthesis Two independent reviewers extracted data from eligible studies. Data were extracted for the intention-to-treat (ITT) and per-protocol (PP) populations. The study is reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures Overall and complete pain response at 1, 3, and 6 months after radiotherapy, according to the study's definition. Relative risk ratios (RRs) with 95% CIs were calculated for each study. A random-effects model using a restricted maximum likelihood estimator was applied for meta-analysis. Results There were 18 studies with 1685 patients included in the systematic review and 8 RCTs with 1090 patients were included in the meta-analysis. In 7 RCTs, overall pain response was defined according to the International Consensus on Palliative Radiotherapy Endpoints in clinical trials (ICPRE). The complete pain response was reported in 6 RCTs, all defined according to the ICPRE. The ITT meta-analyses showed that the overall pain response rates did not differ between cEBRT and SBRT at 1 (RR, 1.14; 95% CI, 0.99-1.30), 3 (RR, 1.19; 95% CI, 0.96-1.47), or 6 (RR, 1.22; 95% CI, 0.96-1.54) months. However, SBRT was associated with a higher complete pain response at 1 (RR, 1.43; 95% CI, 1.02-2.01), 3 (RR, 1.80; 95% CI, 1.16-2.78), and 6 (RR, 2.47; 95% CI, 1.24-4.91) months after radiotherapy. The PP meta-analyses showed comparable results. Conclusions and Relevance In this systematic review and meta-analysis, patients with painful bone metastases experienced similar overall pain response after SBRT compared with cEBRT. More patients had complete pain alleviation after SBRT, suggesting that selected subgroups will benefit from SBRT.
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Affiliation(s)
- Bas J. J. Bindels
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Carole Mercier
- Department of Radiation Oncology, Iridium Netwerk, Antwerpen, Belgium
- Integrated Personalised and Precision Oncology Network, University Antwerp, Antwerp, Belgium
| | - Roxanne Gal
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joost J. C. Verhoeff
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Netwerk, Antwerpen, Belgium
- Integrated Personalised and Precision Oncology Network, University Antwerp, Antwerp, Belgium
| | - Piet Ost
- Department of Radiation Oncology, Iridium Netwerk, Antwerpen, Belgium
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Nicolien Kasperts
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yvette M. van der Linden
- Department of Radiation Oncology and Centre of Expertise in Palliative Care, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | - Helena M. Verkooijen
- Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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10
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Ahmed S, Prakash A, Kumar Upadhyay A. Evaluation of Different Regimens of Palliative Radiation Therapy for Symptomatic Bone Metastases: An Audit From a Tertiary Care Hospital in Jharkhand, India. Cureus 2024; 16:e53622. [PMID: 38449966 PMCID: PMC10916909 DOI: 10.7759/cureus.53622] [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] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
Background This study aimed to assess the efficacy of different radiation therapy regimens in treating patients with symptomatic bone metastases. Methodology A retrospective study was conducted by assigning patients with symptomatic bone metastases from different primary cancers into three groups, namely, Arms A, B, and C. The radiation dose delivered in each arm was as follows: 8 Gray (Gy) in a single fraction for Arm A, 20 Gy in five fractions at the rate of 4 Gy per fraction for Arm B, and 30 Gy in 10 fractions at the rate of 3 Gy per fraction for Arm C. Each arm consisted of 15 patients. A comparison was conducted across all three arms to evaluate pain relief based on the Visual Analog Scale (VAS), performance score improvement based on the Eastern Cooperative Oncology Group (ECOG), and analgesic requirement based on the World Health Organization (WHO) step ladder at one week, one month, and three months. Results The pain relief was measured using the VAS in three different arms, i.e., Arm A, B, and C. After one week, the pain relief was 66.67%, 60%, and 60%, respectively. After one month, it was 73.33% in all three arms. At three months, it was 80%, 86.67%, and 86.67%, respectively. The study also measured the improvement in the ECOG performance score. The improvement in all three arms was 60% after one week and 66.67% in Arm A and 73.33% in Arms B and C after one month. After three months, the improvement was 73.33%, 80%, and 80% in Arms A, B, and C, respectively. The decrease in analgesic usage was also measured in all three arms. After one week, it was 60% in all three arms. After one month, it was 66.67%, 73.33%, and 73.33% in Arms A, B, and C, respectively. At three months, it was 73.33%, 80%, and 80% in Arms A, B, and C, respectively. No significant statistical difference was found between the three arms. Conclusions The efficacy of a single 8 Gy arm was almost equivalent to that of other arms of multifractionated regimens in terms of improvement in pain and performance score and decreased use of analgesics for a short duration of follow-up. For high-volume cancer centers and patients with economic constraints, a single-fraction regime provides effective palliation for painful bone metastases.
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Affiliation(s)
- Suhail Ahmed
- Radiation Oncology, Meherbai Tata Memorial Hospital, Jamshedpur, IND
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11
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Sari SY, Demir N, Yazici G. Stereotactic Radiosurgery vs Conventional Radiotherapy for Spine Metastases. JAMA Oncol 2024; 10:259. [PMID: 38127328 DOI: 10.1001/jamaoncol.2023.6077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Sezin Yuce Sari
- Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey
| | - Nihat Demir
- Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey
| | - Gozde Yazici
- Department of Radiation Oncology, Hacettepe University Medical School, Ankara, Turkey
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12
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Starling MTM, Thibodeau S, de Sousa CFPM, Restini FCF, Viani GA, Gouveia AG, Mendez LC, Marta GN, Moraes FY. Optimizing Clinical Implementation of Hypofractionation: Comprehensive Evidence Synthesis and Practical Guidelines for Low- and Middle-Income Settings. Cancers (Basel) 2024; 16:539. [PMID: 38339290 PMCID: PMC10854666 DOI: 10.3390/cancers16030539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 02/12/2024] Open
Abstract
The global cancer burden, especially in low- and middle-income countries (LMICs), worsens existing disparities, amplified by the rising costs of advanced treatments. The shortage of radiation therapy (RT) services is a significant issue in LMICs. Extended conventional treatment regimens pose significant challenges, especially in resource-limited settings. Hypofractionated radiotherapy (HRT) and ultra-hypofractionated/stereotactic body radiation therapy (SBRT) offer promising alternatives by shortening treatment durations. This approach optimizes the utilization of radiotherapy machines, making them more effective in meeting the growing demand for cancer care. Adopting HRT/SBRT holds significant potential, especially in LMICs. This review provides the latest clinical evidence and guideline recommendations for the application of HRT/SBRT in the treatment of breast, prostate, and lung cancers. It emphasizes the critical importance of rigorous training, technology, stringent quality assurance, and safety protocols to ensure precise and secure treatments. Additionally, it addresses practical considerations for implementing these treatments in LMICs, highlighting the need for comprehensive support and collaboration to enhance patient access to advanced cancer care.
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Affiliation(s)
| | - Stephane Thibodeau
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, ON K7L 3N6, Canada
| | | | | | - Gustavo A. Viani
- Department of Medical Imagings, Ribeirão Preto Medical School, Hematology and Oncology of University of São Paulo (FMRP-USP), Ribeirão Preto 14049-900, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
| | - Andre G. Gouveia
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
- Division of Radiation Oncology, Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Lucas C. Mendez
- Division of Radiation Oncology, Department of Oncology, London Health Sciences Centre, London, ON N6A 5W9, Canada
| | - Gustavo Nader Marta
- Radiation Oncology Department, Hospital Sirio Libanês, Sao Paulo 01308-050, Brazil
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
| | - Fabio Ynoe Moraes
- Division of Radiation Oncology, Department of Oncology, Kingston General Hospital, Queen’s University, Kingston, ON K7L 3N6, Canada
- Latin America Cooperative Oncology Group (LACOG), Porto Alegre 90619-900, Brazil
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13
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Yuan X, Chen J, Shi D, Song J, Wang P, Cheng D, Yang C, Qiu X, Zhai C. Advanced esophageal cancer with bone metastases: Prognostic biomarkers and palliative treatment. Heliyon 2024; 10:e23510. [PMID: 38170113 PMCID: PMC10758821 DOI: 10.1016/j.heliyon.2023.e23510] [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: 09/17/2023] [Revised: 11/16/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
Esophageal cancer (EC) is a common and devastating tumor of the upper digestive tract. Unfortunately, by the time any symptoms have manifested, the disease has often progressed to an advanced stage and is accompanied by macro- and micrometastases, including in the bones. The treatment of esophageal cancer with bone metastases remains clinically challenging, given the poor prognosis associated with this condition. Effective prognostic biomarkers can help medical staff choose the appropriate operation and treatment plan, that is for most beneficial for making patients. Current treatments for esophageal cancer with bone metastases include pain-relieving drugs, surgical therapy, radiotherapy (RT), chemotherapy (CT, including molecular-targeted drug therapy), endocrine therapy (ET), bisphosphonates (BPs) and interventional therapy. Of these robust measures, radiotherapy has emerged as a particularly promising therapy for bone metastases from esophageal cancer. Substantial progress has been made in radiation therapy techniques since the discovery of X-rays by Roentgen in 1895. In its palliative capacity, the key goals of radiotherapy are to relieve the patients' bone pain and debilitate effects, including relieving spinal cord compression, correcting the spinal deformity and restoring spinal stability. However, it is worth mentioning that RT for esophageal cancer has various side effects. Currently, the available studies focused exclusively on radiotherapy for ECBM are too small to draw any definitive conclusions, and each of these studies has significant limitations. In this review, in addition to the epidemiology described at the beginning, we will explore the current prognostic biomarkers and radiotherapy for esophageal cancer, with a particular focus on those with bone metastases.
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Affiliation(s)
- Xiaofeng Yuan
- The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jun Chen
- Department of Orthopedics, Yixing People's Hospital, Yixing, China
| | - Dingsen Shi
- The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jiaxun Song
- The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Pu Wang
- The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Dong Cheng
- The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Cheng Yang
- The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xubin Qiu
- The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Chenjun Zhai
- Department of Orthopedics, Yixing People's Hospital, Yixing, China
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14
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Rothrock RJ, Ozair A, Avendano MC, Herrera S, Appel H, Ramos S, Starosciak AK, Leon-Ariza DS, Rubens M, McDermott MW, Ahluwalia MS, Mehta MP, Kotecha RR. Prophylactic Radiotherapy Of MInimally Symptomatic Spinal Disease (PROMISSeD): study protocol for a randomized controlled trial. Trials 2024; 25:41. [PMID: 38217032 PMCID: PMC10785467 DOI: 10.1186/s13063-023-07850-8] [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: 06/18/2023] [Accepted: 12/03/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Early palliative/pre-emptive intervention improves clinical outcomes and quality of life for patients with metastatic cancer. A previous signal-seeking randomized controlled trial (RCT) demonstrated that early upfront radiotherapy to asymptomatic or minimally symptomatic high-risk osseous metastases led to reduction in skeletal-related events (SREs), a benefit driven primarily by subgroup of high-risk spine metastasis. The current RCT aims to determine whether early palliative/pre-emptive radiotherapy in patients with high-risk, asymptomatic or minimally symptomatic spine metastases will lead to fewer SREs within 1 year. METHODS This is a single-center, parallel-arm, in-progress RCT in adults (≥ 18 years) with ECOG performance status 0-2 and asymptomatic or minimally symptomatic (not requiring opioids) high-risk spine metastases from histologically confirmed solid tumor malignancies with > 5 sites of metastatic disease on cross-sectional imaging. High-risk spine metastases are defined by the following: (a) bulkiest disease sites ≥ 2 cm; (b) junctional disease (occiput to C2, C7-T1, T12-L2, L5-S1); (c) posterior element involvement; or (d) vertebral body compression deformity > 50%. Patients are randomized 1:1 to receive either standard-of-care systemic therapy (arm 1) or upfront, early radiotherapy to ≤ 5 high-risk spine lesions plus standard-of-care systemic therapy (arm 2), in the form of 20-30 Gy of radiation in 2-10 fractions. The primary endpoint is SRE, a composite outcome including spinal fracture, spinal cord compression, need for palliative radiotherapy, interventional procedures, or spinal surgery. Secondary endpoints include (1) surrogates of health care cost, including the number and duration of SRE-related hospitalizations; (2) overall survival; (3) pain-free survival; and (4) quality of life. Study instruments will be captured pre-treatment, at baseline, during treatment, and at 1, 3, 6, 12, and 24 months post-treatment. The trial aims to accrue 74 patients over 2 years to achieve > 80% power in detecting difference using two-sample proportion test with alpha < 0.05. DISCUSSION The results of this RCT will demonstrate the value, if any, of early radiotherapy for high-risk spine metastases. The trial has received IRB approval, funding, and prospective registration (NCT05534321) and has been open to accrual since August 19, 2022. If positive, the trial will expand the scope and utility of spine radiotherapy. TRIAL REGISTRATION ClinicalTrials.Gov NCT05534321 . Registered September 9, 2022. TRIAL STATUS Version 2.0 of the protocol (2021-KOT-002), revised last on September 2, 2022, was approved by the WCG institutional review board (Study Number 1337188, IRB tracking number 20223735). The trial was first posted on ClinicalTrials.Gov on September 9, 2022 (NCT05534321). Patient enrollment commenced on August 19, 2022, and is expected to be completed in 2 years, likely by August 2024.
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Affiliation(s)
- Robert J Rothrock
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ahmad Ozair
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Maria C Avendano
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Susana Herrera
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Haley Appel
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Suyen Ramos
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Amy K Starosciak
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Daniel S Leon-Ariza
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Muni Rubens
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
| | - Michael W McDermott
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Manmeet S Ahluwalia
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Minesh P Mehta
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Rupesh R Kotecha
- Office 1R203, Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, 33176, USA.
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
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15
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Nakata E, Sugihara S, Nakahara R, Katayama H, Itano T, Ozaki T. Changes in Spinal Instability After Conventional Radiotherapy for Painful Vertebral Bone Metastases. Cancer Control 2024; 31:10732748241250219. [PMID: 38686892 PMCID: PMC11062211 DOI: 10.1177/10732748241250219] [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: 08/06/2023] [Revised: 03/12/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVE Precise assessment of spinal instability is critical before and after radiotherapy (RT) for evaluating the effectiveness of RT. Therefore, we retrospectively evaluated the efficacy of RT in spinal instability over a period of 6 months after RT, utilizing the spinal instability neoplastic score (SINS) in patients with painful spinal metastasis. We retrospectively evaluated 108 patients who received RT for painful vertebral metastasis in our institution. Mechanical pain at metastatic vertebrae, radiological responses of irradiated vertebrae, and spinal instability were assessed. Follow-up assessments were done at the start of and at intervals of 1, 2, 3, 4, and 6 months after RT, with the pain disappearing in 67%, 85%, 93%, 97%, and 100% of the patients, respectively. The median SINS were 8, 6, 6, 5, 5, and 4 at the beginning and after 1, 2, 3, 4, and 6 months of RT, respectively. Multivariate analysis revealed that posterolateral involvement of spinal elements (PLISE) was the only risk factor for continuous potentially unstable/unstable spine at 1 month. In conclusion, there was improvement of pain, and recalcification results in regaining spinal stability over time after RT although vertebral body collapse and malalignment occur in some irradiated vertebrae. Clinicians should pay attention to PLISE in predicting continuous potentially unstable/unstable spine.
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Affiliation(s)
- Eiji Nakata
- Department of Orthopedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Shinsuke Sugihara
- Department of Orthopedic Surgery, Shikoku Cancer Center, Matsuyama, Japan
| | - Ryuichi Nakahara
- Department of Orthopedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Haruyoshi Katayama
- Department of Orthopedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Takuto Itano
- Department of Orthopedic Surgery, Okayama University Hospital, Okayama, Japan
| | - Toshifumi Ozaki
- Department of Orthopedic Surgery, Okayama University Hospital, Okayama, Japan
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16
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Davis MP, Vanenkevort E, Young A, Wojtowicz M, Gupta M, Lagerman B, Liu E, Mackley H, Panikkar R. Radiation Therapy in the Last Month of Life: Association With Aggressive Care at the End of Life. J Pain Symptom Manage 2023; 66:638-646. [PMID: 37657725 DOI: 10.1016/j.jpainsymman.2023.08.024] [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: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/03/2023]
Abstract
CONTEXT Half of the patients with cancer who undergo radiation therapy do so with palliative intent. OBJECTIVES To determine the proportion of undergoing radiation in the last month of life, patient characteristics, cancer course, the type and duration of radiation, whether palliative care was involved, and the of radiation with aggressive cancer care metrics. METHODS One thousand seven hundred twenty-seven patients who died of cancer between January 1, 2018, and December 31, 2019, were included. Demographics, cancer stage, palliative care referral, advance directives, use of home health care, radiation timing, and survival were collected. Type of radiation, course, and intent were reviewed. Chi-square analysis was utilized for categorical variables, and Kruskal-Wallis tests for continuous variables. A stepwise selection was used to build a Cox proportional hazard model. RESULTS Two hundred thirty-three patients underwent radiation in the last month of life. Younger patients underwent radiation 67.3 years (SD 11.52) versus 69.2 years (SD 11.96). 42.6% had radiation within two weeks of death. The average fraction number was 5.5. Individuals undergoing radiation were more likely to start chemotherapy within the last 30 days of life, continue chemotherapy within two weeks of death, be admitted to the ICU, and have two or more hospitalizations or emergency room visits. Survival measured from the date of diagnosis was shorter for those undergoing radiation, 122 days (IQR 58-462) versus 474 days (IQR 225-1150). Palliative care consultations occurred later in those undergoing radiation therapy. CONCLUSION Radiation therapy in the last month of life occurs in younger patients with rapidly progressive cancer, who are subject to more aggressive cancer care, and have late palliative care consults.
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Affiliation(s)
- Mellar P Davis
- Department of Palliative Care (M.P.D.), Geisinger Medical Center, Danville, Pennsylvania.
| | - Erin Vanenkevort
- Department of Population and Health Science (E.V., A.Y.), Research Institute Geisinger Health System, Danville, Pennsylvania
| | - Amanda Young
- Department of Population and Health Science (E.V., A.Y.), Research Institute Geisinger Health System, Danville, Pennsylvania
| | - Mark Wojtowicz
- Oncology Research Department (M.W.), Cancer Institute, Geisinger Medical Center, Danville, Pennsylvania
| | - Mudit Gupta
- Department of Phenomics Analytics and Clinical Data Core (M.G., B.L.), Geisinger Health System, Danville, Pennsylvania
| | - Braxton Lagerman
- Department of Phenomics Analytics and Clinical Data Core (M.G., B.L.), Geisinger Health System, Danville, Pennsylvania
| | - Edward Liu
- Geisinger Commonwealth School of Medicine (E.L.), Danville, Pennsylvania
| | - Heath Mackley
- Department of Radiation Oncology (H.M.), Geisinger Medical Center, Danville, Pennsylvania
| | - Rajiv Panikkar
- Knapper Cancer Center, Geisinger Medical Center (R.P.), Danville, Pennsylvania
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17
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Kawamoto T, Saito T, Nakamura N, Shikama N. Moderate adverse events and regional differences in CDK4/6 inhibitor treatment combined with palliative radiotherapy. Radiother Oncol 2023; 188:109907. [PMID: 37690667 DOI: 10.1016/j.radonc.2023.109907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, Tokyo, Japan.
| | - Tetsuo Saito
- Department of Radiation Oncology, Arao Municipal Hospital, Kumamoto, Japan
| | - Naoki Nakamura
- Department of Radiation Oncology, St. Marianna University School of Medicine Hospital, Kawasaki, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, Tokyo, Japan
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18
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Leland CR, Morris CD, Forsberg JA, Levin AS. Functional outcomes after open reconstruction or nonoperative management of 81 pathologic acetabular fractures from metastatic bone disease. J Orthop 2023; 44:22-30. [PMID: 37654617 PMCID: PMC10466429 DOI: 10.1016/j.jor.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 09/02/2023] Open
Abstract
Background Pathologic acetabular fracture secondary to skeletal metastasis may result in debilitating pain, inability to ambulate, and impaired quality of life, which may mark the first period of dependent care in cancer patients. Acetabular reconstruction may involve morbid procedures with increased complication rates. This study aimed to evaluate the evolution of pain, performance status, and ambulation following nonoperative management or open reconstruction of pathologic acetabular fractures. Methods A retrospective cohort of 2630 adult patients with osseous metastatic disease treated at a high-volume cancer center between 2005 and 2021 was screened for pathologic fractures of the acetabulum. The study outcomes were pain, performance status, and the ability to ambulate. We identified 78 patients (median age, 60 years; 37 female patients [46%]) with 81 fractures. Of these, treatment consisted of open reconstruction (n = 34) or nonoperative management alone (n = 47). The mean follow-up in surviving patients was 3.4 years. Results Open reconstruction was performed more frequently for displaced fractures (P < 0.01), Harrington class III or IV acetabula (P < 0.01), and patients with a performance status ≥3 at hospitalization (P = 0.00). Open reconstruction was associated with clinically meaningful improvements in pain (adjusted odds ratio [aOR], 8.3; 95% CI, 1.4-50.6; P = 0.02) and performance status (aOR, 10.9; 95% CI, 1.7-71.0; P = 0.01) at discharge and a restoration of ambulation (aOR, 7.5; 95% CI, 1.9-29.8; P < 0.01) at final follow-up. Conclusions In patients with pathologic acetabular fracture due to osseous metastatic disease, functional improvements in pain, performance status, and ambulation were observed following open acetabular reconstruction in carefully selected patients, with no impact on survival, while noninferior improvements were observed in patients receiving nonoperative management when considering their larger clinical context. Level of evidence Level III, therapeutic study.
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Affiliation(s)
- Christopher R. Leland
- Harvard Combined Orthopaedic Residency Program, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
- Division of Oncology, Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Carol D. Morris
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Division of Oncology, Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan A. Forsberg
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Division of Oncology, Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Adam S. Levin
- Division of Oncology, Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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19
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Nguyen EK, Korol R, Ali S, Cumal A, Erler D, Louie AV, Nguyen TK, Poon I, Cheung P, Chu W, Soliman H, Vesprini D, Sahgal A, Chen H. Predictors of pathologic fracture and local recurrence following stereotactic body radiation therapy to 505 non-spine bone metastases. Radiother Oncol 2023; 186:109792. [PMID: 37414253 DOI: 10.1016/j.radonc.2023.109792] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Abstract
PURPOSE Stereotactic Body Radiation Therapy (SBRT) is increasingly applied to treat non-spine bone metastases (NSBM) though data remains limited on this approach. In this retrospective study, we report outcomes and predictors of local failure (LF) and pathological fracture (PF) post-SBRT for NSBM using a mature single-institution database. METHODS Patients with NSBM treated with SBRT between 2011 and 2021 were identified. The primary objective was to assess the rates of radiographic LF. Secondary objectives were to assess the rates of in-field PF, overall survival (OS), and late grade ≥ 3 toxicity. Competing risks analysis was used to assess rates of LF and PF. Univariable regression and multivariable regression (MVR) were performed to investigate predictors of LF and PF. RESULTS A total of 373 patients with 505 NSBM were included in this study. Median follow-up was 26.5 months. The cumulative incidence of LF at 6, 12, and 24 months were 5.7%, 7.9%, and 12.6%, respectively. The cumulative incidence of PF at 6, 12, and 24 months were 3.8%, 6.1%, and 10.9%, respectively. Lytic NSBM (HR = 2.18; p < 0.01), a lower biologically effective dose (HR = 1.11 per 5 Gy10 decrease; p = 0.04), and a PTV ≥ 54 cc (HR = 4.32; p < 0.01) predicted for a higher risk of LF on MVR. Lytic NSBM (HR = 3.43; p < 0.01), mixed (lytic/sclerotic) lesions (HR = 2.70; p = 0.04), and rib metastases (HR = 2.68; p < 0.01) predicted for a higher risk of PF on MVR. CONCLUSION SBRT is an effective modality to treat NSBM with high rates of radiographic local control with an acceptable rate of PF. We identify predictors of both LF and PF that can serve to inform practice and trial design.
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Affiliation(s)
- Eric K Nguyen
- Department of Radiation Oncology, Walker Family Cancer Center, Niagara Health, St. Catharines, Ontario L2S 0A9, Canada
| | - Renee Korol
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Saher Ali
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Aaron Cumal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Darby Erler
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Center, Western University, London, Ontario N6A 5W9, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Patrick Cheung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - William Chu
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Danny Vesprini
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario M4N 3M5, Canada.
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20
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Park J, Lee JE. Comparison between 1-week and 2-week palliative radiotherapy courses for superior vena cava syndrome. Radiat Oncol J 2023; 41:178-185. [PMID: 37793627 PMCID: PMC10556839 DOI: 10.3857/roj.2023.00626] [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: 07/20/2023] [Revised: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023] Open
Abstract
PURPOSE The aim of this study was to evaluate the effectiveness of palliative radiation therapy (RT) for superior vena cava (SVC) syndrome from lung cancer and to compare the 2-week and 1-week schedules. MATERIALS AND METHODS A retrospective study was conducted on lung cancer patients with palliative RT for SVC syndrome. Patients received 30 Gy in 10 fractions (2-week group) or 20 Gy in 5 fractions (1-week group) between July 2012 and June 2022. Treatment outcomes were evaluated at 1 to 2 months after RT. The tumor response and recanalization were evaluated based on the computed tomography (CT). RESULTS Of the 39 patients, 24 received a 2-week course RT and 15 received a 1-week course of RT. The most common SVC-associated symptoms were edema (51.3%) and dyspnea (43.6%). There were no significant differences in performance status, histology, and grade of SVC. Symptom relief in symptomatic patients was comparable (85.7% in the 2-week group vs. 91.6% in the 1-week group; p = 0.581). There were no significant differences between the 2-week and 1-week groups in recanalization rates (62.5% vs. 60.0%; p = 0.876), tumor responses (75% vs. 60.0%; p = 0.876), and 6-month overall survival rates (29.2% vs. 36.4%; p = 0.726). In each of the two groups, one patient was consulted for re-irradiation. The median survival were 3.7 months for the 2-week group and 4.4 months for the 1-week group. CONCLUSION In patients with SVC syndrome, the palliative effect of a 1-week course was equivalent to that of a 2-week course. Given the poor prognosis, a 1-week course may be an option.
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Affiliation(s)
- Jongmoo Park
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeong Eun Lee
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Daegu, Korea
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21
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Arsenijević T, Stepanović A, Milošević‐Maračić B, Poparić‐Bandjur B, Mišković I, Gavrilović D, Nikitović M. What did COVID-19 pandemics teach us about single-fraction radiotherapy for painful bone metastases-State of the art or undertreatment? Cancer Med 2023; 12:15912-15921. [PMID: 37317639 PMCID: PMC10469708 DOI: 10.1002/cam4.6231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/25/2023] [Accepted: 06/01/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Choosing the optimal treatment approach for patients with painful bone metastases during the COVID-19 pandemic became challenging. A simple technique, single fraction radiotherapy was recommended for these patients usually referring to bone metastases as a single entity, although it is a very heterogeneous group of patients. AIM This study aimed to analyze the response to palliative single fraction radiotherapy in relation to age, performance status, primary tumor, histopathology, and bone localization in the group of patients with painful bone metastases. METHODS A clinical, prospective, non-randomized study was conducted at the Institute for Oncology and Radiology of Serbia, which included 64 patients with noncomplicated, painful bone metastases who underwent palliative, pain-relieving radiation therapy with a single tumor dose of 8Gy in a single hospital visit. Response to treatment was patient reported via telephone interview using visual analog scale. The response assessment was based on the international consensus panel of radiation oncologists. RESULTS In the entire group of patients, 83% responded to radiotherapy. No statistically significant difference was observed in response to therapy, time to reach the maximum response, degree of pain reduction, nor in response duration depending on the patient's age, performance status, the primary origin of the tumor, histopathology, or location of the metastasis (bone) that was irradiated. CONCLUSION Regardless of clinical parameters, palliative radiotherapy with a single dose of 8Gy can be considered very effective in quick pain relief in patients with noncomplicated painful bone metastases. Single fraction radiotherapy in a single hospital visit, as well as patient-reported outcome for these patients may be considered favorable beyond Covid pandemics.
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Affiliation(s)
- Tatjana Arsenijević
- University of Belgrade, Faculty of MedicineBelgradeSerbia
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
| | - Aleksandar Stepanović
- University of Belgrade, Faculty of MedicineBelgradeSerbia
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
| | | | | | - Ivana Mišković
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
| | | | - Marina Nikitović
- University of Belgrade, Faculty of MedicineBelgradeSerbia
- Institute for Oncology and Radiology of SerbiaBelgradeSerbia
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22
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Ryu S, Deshmukh S, Timmerman RD, Movsas B, Gerszten P, Yin FF, Dicker A, Abraham CD, Zhong J, Shiao SL, Tuli R, Desai A, Mell LK, Iyengar P, Hitchcock YJ, Allen AM, Burton S, Brown D, Sharp HJ, Dunlap NE, Siddiqui MS, Chen TH, Pugh SL, Kachnic LA. Stereotactic Radiosurgery vs Conventional Radiotherapy for Localized Vertebral Metastases of the Spine: Phase 3 Results of NRG Oncology/RTOG 0631 Randomized Clinical Trial. JAMA Oncol 2023; 9:800-807. [PMID: 37079324 PMCID: PMC10119775 DOI: 10.1001/jamaoncol.2023.0356] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/23/2023] [Indexed: 04/21/2023]
Abstract
Importance Spine metastasis can be treated with high-dose radiation therapy with advanced delivery technology for long-term tumor and pain control. Objective To assess whether patient-reported pain relief was improved with stereotactic radiosurgery (SRS) as compared with conventional external beam radiotherapy (cEBRT) for patients with 1 to 3 sites of vertebral metastases. Design, Setting, and Participants In this randomized clinical trial, patients with 1 to 3 vertebral metastases were randomized 2:1 to the SRS or cEBRT groups. This NRG 0631 phase 3 study was performed as multi-institutional enrollment within NRG Oncology. Eligibility criteria included the following: (1) solitary vertebral metastasis, (2) 2 contiguous vertebral levels involved, or (3) maximum of 3 separate sites. Each site may involve up to 2 contiguous vertebral bodies. A total of 353 patients enrolled in the trial, and 339 patients were analyzed. This analysis includes data extracted on March 9, 2020. Interventions Patients randomized to the SRS group were treated with a single dose of 16 or 18 Gy (to convert to rad, multiply by 100) given to the involved vertebral level(s) only, not including any additional spine levels. Patients assigned to cEBRT were treated with 8 Gy given to the involved vertebra plus 1 additional vertebra above and below. Main Outcomes and Measures The primary end point was patient-reported pain response defined as at least a 3-point improvement on the Numerical Rating Pain Scale (NRPS) without worsening in pain at the secondary site(s) or the use of pain medication. Secondary end points included treatment-related toxic effects, quality of life, and long-term effects on vertebral bone and spinal cord. Results A total of 339 patients (mean [SD] age of SRS group vs cEBRT group, respectively, 61.9 [13.1] years vs 63.7 [11.9] years; 114 [54.5%] male in SRS group vs 70 [53.8%] male in cEBRT group) were analyzed. The baseline mean (SD) pain score at the index vertebra was 6.06 (2.61) in the SRS group and 5.88 (2.41) in the cEBRT group. The primary end point of pain response at 3 months favored cEBRT (41.3% for SRS vs 60.5% for cEBRT; difference, -19 percentage points; 95% CI, -32.9 to -5.5; 1-sided P = .99; 2-sided P = .01). Zubrod score (a measure of performance status ranging from 0 to 4, with 0 being fully functional and asymptomatic, and 4 being bedridden) was the significant factor influencing pain response. There were no differences in the proportion of acute or late adverse effects. Vertebral compression fracture at 24 months was 19.5% with SRS and 21.6% with cEBRT (P = .59). There were no spinal cord complications reported at 24 months. Conclusions and Relevance In this randomized clinical trial, superiority of SRS for the primary end point of patient-reported pain response at 3 months was not found, and there were no spinal cord complications at 2 years after SRS. This finding may inform further investigation of using spine radiosurgery in the setting of oligometastases, where durability of cancer control is essential. Trial Registration ClinicalTrials.gov Identifier: NCT00922974.
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Affiliation(s)
- Samuel Ryu
- Department of Radiation Oncology, Stony Brook University Health Science Center, Stony Brook, New York
| | - Snehal Deshmukh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
- American College of Radiology, Philadelphia, Pennsylvania
| | | | | | - Peter Gerszten
- University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | | | - Adam Dicker
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Jim Zhong
- Emory University Hospital, Atlanta, Georgia
| | | | | | - Anand Desai
- Summa Akron City Hospital/Cooper Cancer Center, Akron, Ohio
| | - Loren K. Mell
- University of California San Diego Moores Cancer Center, La Jolla
| | - Puneeth Iyengar
- University of Texas Southwestern/Simmons Cancer Center–Dallas
| | | | | | - Steven Burton
- University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Doris Brown
- Wake Forest University Health Sciences, Winston Salem, North Carolina
| | | | - Neal E. Dunlap
- The James Graham Brown Cancer Center at University of Louisville, Louisville, Kentucky
| | | | | | - Stephanie L. Pugh
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
- American College of Radiology, Philadelphia, Pennsylvania
| | - Lisa A. Kachnic
- Columbia University Irving Medical Center, New York, New York
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23
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Tubin S, Vozenin M, Prezado Y, Durante M, Prise K, Lara P, Greco C, Massaccesi M, Guha C, Wu X, Mohiuddin M, Vestergaard A, Bassler N, Gupta S, Stock M, Timmerman R. Novel unconventional radiotherapy techniques: Current status and future perspectives - Report from the 2nd international radiation oncology online seminar. Clin Transl Radiat Oncol 2023; 40:100605. [PMID: 36910025 PMCID: PMC9996385 DOI: 10.1016/j.ctro.2023.100605] [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: 12/14/2022] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023] Open
Abstract
•Improvement of therapeutic ratio by novel unconventional radiotherapy approaches.•Immunomodulation using high-dose spatially fractionated radiotherapy.•Boosting radiation anti-tumor effects by adding an immune-mediated cell killing.
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Affiliation(s)
- S. Tubin
- Medaustron Center for Ion Therapy, Marie-Curie Strasse 5, Wiener Neustadt 2700, Austria
- Corresponding author.
| | - M.C. Vozenin
- Radiation Oncology Laboratory, Radiation Oncology Service, Oncology Department, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Y. Prezado
- Institut Curie, Université PSL, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, Orsay 91400, France
- Université Paris-Saclay, CNRS UMR3347, Inserm U1021, Signalisation Radiobiologie et Cancer, Orsay 91400, France
| | - M. Durante
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung, Planckstraße 1, Darmstadt 64291, Germany
- Technsiche Universität Darmstadt, Institute for Condensed Matter Physics, Darmstadt, Germany
| | - K.M. Prise
- Patrick G Johnston Centre for Cancer Research Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7AE, United Kingdom
| | - P.C. Lara
- Canarian Comprehensive Cancer Center, San Roque University Hospital & Fernando Pessoa Canarias University, C/Dolores de la Rocha 9, Las Palmas GC 35001, Spain
| | - C. Greco
- Department of Radiation Oncology Champalimaud Foundation, Av. Brasilia, Lisbon 1400-038, Portugal
| | - M. Massaccesi
- UOC di Radioterapia Oncologica, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - C. Guha
- Montefiore Medical Center Radiation Oncology, 111 E 210th St, New York, NY, United States
| | - X. Wu
- Executive Medical Physics Associates, 19470 NE 22nd Road, Miami, FL 33179, United States
| | - M.M. Mohiuddin
- Northwestern Medicine Cancer Center Warrenville and Northwestern Medicine Proton Center, 4455 Weaver Pkwy, Warrenville, IL 60555, United States
| | - A. Vestergaard
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - N. Bassler
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - S. Gupta
- The Loop Immuno-Oncology Laboratory, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States
| | - M. Stock
- Medaustron Center for Ion Therapy, Marie-Curie Strasse 5, Wiener Neustadt 2700, Austria
- Karl Landsteiner University of Health Sciences, Marie-Curie Strasse 5, Wiener Neustadt 2700, Austria
| | - R. Timmerman
- Department of Radiation Oncology, University of Texas, Southwestern Medical Center, Inwood Road Dallas, TX 2280, United States
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24
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Heptonstall N, Scott-Warren J, Berman R, Filippiadis D, Bell J. Role of interventional radiology in pain management in oncology patients. Clin Radiol 2023; 78:245-253. [PMID: 35811156 DOI: 10.1016/j.crad.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 11/27/2022]
Abstract
This article reviews the current evidence of interventional radiology procedures for patients suffering with debilitating cancer pain, refractory to conventional therapies. Cancer pain is notoriously difficult to treat. Up to 90% of cancer patients experience pain with 56-82% of cancer pain controlled inadequately. Cancer pain influences a patient's ability to perform normal daily activities, causes higher risk of depression, and reduces quality of life. Pain-free status has been universally voted as a "good death". Alternative minimally invasive options include nerve blocks, neurolysis, bone ablation, spine and peripheral musculoskeletal augmentation techniques, embolisation, and cordotomy with evidence highlighting improved pain control, reduced analgesic requirements, and improved quality of life. Unfortunately, awareness and availability of these procedures is limited, potentially leaving patients suffering during their remaining life. The purpose of this review is to describe the basic concepts of interventional radiology techniques for pain palliation in oncology patients. In addition, emphasis will be given upon the need for an individually tailored approach aiming to augment efficacy and safety.
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Affiliation(s)
- N Heptonstall
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK.
| | - J Scott-Warren
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - R Berman
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - D Filippiadis
- Department of Radiology, Attikon University Hospital, Athens, Greece
| | - J Bell
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
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25
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Sudmeier LJ, Madden N, Zhang C, Brock K, Esiashvili N, Eaton BR. Palliative radiotherapy for children: Symptom response and treatment-associated toxicity according to radiation therapy dose and fractionation. Pediatr Blood Cancer 2023; 70:e30195. [PMID: 36642970 PMCID: PMC10430237 DOI: 10.1002/pbc.30195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 11/08/2022] [Accepted: 12/19/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND/OBJECTIVES Radiotherapy is an effective palliative treatment in advanced cancer. Shorter palliative treatment courses are recommended for adults, though pediatric data addressing treatment efficacy and toxicity according to radiation therapy (RT) dose and fractionation are limited. DESIGN/METHODS Total 213 patients aged 21 years or younger receiving 422 palliative radiotherapy treatment courses from 2003 to 2016 were included. Symptom response and treatment-associated toxicity were recorded and analyzed in relationship to demographic and treatment variables. RESULTS Common diagnoses included sarcoma (32.5%), neuroblastoma (24.9%), leukemia/lymphoma (14.9%), and central nervous system tumors (10.9%). The most common indication for treatment was pain (46.7%). Patients received a median of 10 fractions, 2.5 Gy dose per fraction, and 21 Gy total dose. Number of RT fractions was five or less in 166 (39.3%), six to 10 fractions in 117 (27.2%), and 10 or more fractions in 139 (32.9%) of courses. Complete or partial pain relief was achieved in 85% (151 of 178 evaluable patients), including 77.8% receiving five or less fractions and 89.6% receiving more than five fractions. Highest toxicity was grade 1 in 159 (38.9%), grade 2 in 26 (6.4%), and grade 3 in two (0.5%) treatments. On multivariable analysis, RT delivered 30 or more days from death (OR 12.13, 95% CI: 2.13-69.2, p = .005) and no adjuvant chemotherapy (OR 0.14, 95% CI: 0.03-0.54, p = .005) were significantly associated with pain response, and five or less fractions were significantly associated with lower toxicity (OR 0.24, 95% CI: 0.06-0.97, p = .045). CONCLUSIONS Palliative RT courses of five or less fractions result in high rates of pain control and are associated with low toxicity in pediatric patients with cancer.
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Affiliation(s)
- Lisa J Sudmeier
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Nicholas Madden
- Hulston Cancer Center, CoxHealth, Springfield, Missouri, USA
| | - Chao Zhang
- Department of Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Katharine Brock
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
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26
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Song X, Wei J, Sun R, Jiang W, Chen Y, Shao Y, Gu W. Stereotactic Body Radiation Therapy Versus Conventional Radiation Therapy in Pain Relief for Bone Metastases: A Systematic Review and Meta-Analysis. Int J Radiat Oncol Biol Phys 2023; 115:909-921. [PMID: 36273520 DOI: 10.1016/j.ijrobp.2022.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 09/15/2022] [Accepted: 10/08/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE This study aimed to investigate the difference in pain relief between stereotactic body radiation therapy (SBRT) and conventional radiation therapy (cRT) for patients with bone metastases. METHODS AND MATERIALS Clinical trials and observational studies comparing SBRT versus cRT for bone metastases were retrieved. The main endpoint was pain relief after radiation therapy; the secondary endpoints were pain score change, local progression-free survival, reirradiation rate, and toxic events. When there was a significant heterogeneity, the random-effects model was applied. Otherwise, the fixed-effects model was used. Analyses of all included studies were performed first, followed by analyses of randomized controlled trials (RCTs) only. RESULTS Six RCTs, 1 prospective cohort study, and 3 retrospective observational studies were enrolled. Between 2004 and 2019, 448 patients received SBRT, and 445 patients received cRT. All prospective studies defined the lesions as oligometastatic. Pooled results based on all included studies indicated that SBRT was generally associated with a higher overall relief rate (P < .001 at 3 months; P = .015 at 6 months) and complete relief rate (P = .029 at 1 month; P < .001 at 6 months). Pooled results based on RCTs indicated that at 3 and 6 months, SBRT was associated with a higher overall relief rate (P < .001 and P = .017, respectively) and complete relief rate (P < .001 and P < .00, respectively). Subgroup analyses indicated that in more cases, the analgesic advantage of SBRT was more obvious when spinal lesions were irradiated, when the difference in the mean biological effective dose (BED) was less, or when intensity modulated radiation therapy was used to deliver SBRT. CONCLUSIONS Excessive elevation of BED introduces the risk of diminishing the analgesic effect of SBRT. SBRT delivered using intensity modulated radiation therapy is preferred for pain relief in spinal oligometastases. More RCTs are required to determine the most appropriate BED or dose regimen for SBRT.
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Affiliation(s)
- Xing Song
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Jun Wei
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Rui Sun
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Wenjie Jiang
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Yuan Chen
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Jiangsu, China
| | - Yingjie Shao
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Jiangsu, China.
| | - Wendong Gu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, Jiangsu, China.
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27
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Christ AB, Bartelstein MK, Kenan S, Ogura K, Fujiwara T, Healey JH, Fabbri N. Operative management of metastatic disease of the acetabulum: review of the literature and prevailing concepts. Hip Int 2023; 33:152-160. [PMID: 36225166 DOI: 10.1177/11207000221130270] [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] [Indexed: 02/04/2023]
Abstract
Metastatic disease of the periacetabular region is a common problem in orthopaedic oncology, associated with severe pain, decreased mobility, and substantial decline of the quality of life. Conservative management includes optimisation of pain management, activity modification, and radiation therapy. However, patients with destructive lesions affecting the weight-bearing portion of the acetabulum often require reconstructive surgery to decrease pain and restore mobility. The goal of surgery is to provide an immediately stable and durable construct, allowing immediate postoperative weight-bearing and maintaining functional independence for the remaining lifetime of the patient. A variety of surgical techniques have been reported, most of which are based upon cemented total hip arthroplasty, but also include porous tantalum implants and percutaneous cementoplasty. This review discusses the various reconstructive concepts and options, including their respective indications and outcome. A reconstructive algorithm incorporating different techniques and strategies based upon location and quality of remaining bone is also presented.
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Affiliation(s)
- Alexander B Christ
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Meredith K Bartelstein
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shachar Kenan
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Koichi Ogura
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tomohiro Fujiwara
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John H Healey
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicola Fabbri
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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28
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Lee CC, Tey J, Cheo T, Lee CH, Wong A, Kumar N, Vellayappan B. Outcomes of Patients With Spinal Metastases From Prostate Cancer Treated With Conventionally-Fractionated External Beam Radiation Therapy. Global Spine J 2023; 13:284-294. [PMID: 33648366 PMCID: PMC9972278 DOI: 10.1177/2192568221994798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the outcomes of conventionally-fractionated external beam radiation therapy (cEBRT) in the treatment of prostate cancer spinal metastases (PCSM). METHODS Patients who received palliative cEBRT for PCSM in our institution between 2008 and 2018 were included. Our outcomes were local progression-free survival (LPFS), overall survival (OS), pain response and toxicities graded using CTCAE version 4.03. Univariable and multivariable Cox proportional hazard regressions were performed to identify predictors for LPFS and OS. RESULTS A total of 100 patients with 132 sites of PCSM were identified, with a median follow-up of 54 months. Fourteen-percent of patients underwent surgical intervention before receiving cEBRT. Eighteen spinal segments (13.6%) had local progression, with a median time to local progression of 8 months. The median LPFS and OS were 7.8 and 9.0 months, respectively. The complete and partial pain response rates were 57% and 39% respectively. The incidence of grade ≥3 acute toxicities was 11%. Better ECOG performance status (0 to 1), castration-sensitive disease, spinal surgery and use of novel antiandrogen agent were identified as significant predictors for improved OS on multivariable analysis. CONCLUSIONS In our prostate cancer cohort, cEBRT is an effective treatment modality for local palliation of spinal metastases. More aggressive treatment approach should be considered for patients with excellent performance status and castration-sensitive disease in light of their expected longer survival. Further studies are warranted to identify the predictors for radiotherapy response in this population.
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Affiliation(s)
- Chia Ching Lee
- Department of Radiation Oncology,
National University Cancer Institute, National University Hospital, National
University Health System, National University of Singapore, Singapore,
Singapore
| | - Jeremy Tey
- Department of Radiation Oncology,
National University Cancer Institute, National University Hospital, National
University Health System, National University of Singapore, Singapore,
Singapore
| | - Timothy Cheo
- Department of Radiation Oncology,
National University Cancer Institute, National University Hospital, National
University Health System, National University of Singapore, Singapore,
Singapore
| | - Chau Hung Lee
- Department of Radiology, Tan Tock Seng
Hospital, Singapore, Singapore
| | - Alvin Wong
- Department of Haematology-Oncology,
National University Cancer Institute, National University Hospital, Singapore
| | - Naresh Kumar
- Department of Orthopaedic Surgery,
National University Hospital, National University Health System, National University
of Singapore, Singapore
| | - Balamurugan Vellayappan
- Department of Radiation Oncology,
National University Cancer Institute, National University Hospital, National
University Health System, National University of Singapore, Singapore,
Singapore
- Balamurugan Vellayappan, Department of
Radiation Oncology, National University Cancer Institute, National University
Hospital, National University Health System, National University of Singapore,
1E Kent Ridge Road, NUHS Tower Block, Level 7, 119228 Singapore, Singapore.
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29
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Gupta N, Ochiai H, Hoshino Y, Klein S, Zustin J, Ramjiawan RR, Kitahara S, Maimon N, Bazou D, Chiang S, Li S, Schanne DH, Jain RK, Munn LL, Huang P, Kozin SV, Duda DG. Inhibition of CXCR4 Enhances the Efficacy of Radiotherapy in Metastatic Prostate Cancer Models. Cancers (Basel) 2023; 15:1021. [PMID: 36831366 PMCID: PMC9954510 DOI: 10.3390/cancers15041021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
Radiotherapy (RT) is a standard treatment for patients with advanced prostate cancer (PCa). Previous preclinical studies showed that SDF1α/CXCR4 axis could mediate PCa metastasis (most often to the bones) and cancer resistance to RT. We found high levels of expression for both SDF1α and its receptor CXCR4 in primary and metastatic PCa tissue samples. In vitro analyses using PCa cells revealed an important role of CXCR4 in cell invasion but not radiotolerance. Pharmacologic inhibition of CXCR4 using AMD3100 showed no efficacy in orthotopic primary and bone metastatic PCa models. However, when combined with RT, AMD3100 potentiated the effect of local single-dose RT (12 Gy) in both models. Moreover, CXCR4 inhibition also reduced lymph node metastasis from primary PCa. Notably, CXCR4 inhibition promoted the normalization of bone metastatic PCa vasculature and reduced tissue hypoxia. In conclusion, the SDF1α/CXCR4 axis is a potential therapeutic target in metastatic PCa patients treated with RT.
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Affiliation(s)
- Nisha Gupta
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Hiroki Ochiai
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Yoshinori Hoshino
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Sebastian Klein
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Jozef Zustin
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Rakesh R. Ramjiawan
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Shuji Kitahara
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Nir Maimon
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Despina Bazou
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Sarah Chiang
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Sen Li
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Daniel H. Schanne
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Rakesh. K. Jain
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Lance L. Munn
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Peigen Huang
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Sergey V. Kozin
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Dan G. Duda
- Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Makita K, Hamamoto Y, Kanzaki H, Nagasaki K, Takata N, Tsuruoka S, Uwatsu K, Kido T. Factors Affecting Survival and Local Control in Patients with Bone Metastases Treated with Radiotherapy. Med Sci (Basel) 2023; 11:medsci11010017. [PMID: 36810484 PMCID: PMC9944514 DOI: 10.3390/medsci11010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
The aim of this study was to evaluate the expected prognosis and factors affecting local control (LC) of the bone metastatic sites treated with palliative external beam radiotherapy (RT). Between December 2010 and April 2019, 420 cases (male/female = 240/180; median age [range]: 66 [12-90] years) with predominantly osteolytic bone metastases received RT and were evaluated. LC was evaluated by follow-up computed tomography (CT) image. Median RT doses (BED10) were 39.0 Gy (range, 14.4-71.7 Gy). The 0.5-year overall survival and LC of RT sites were 71% and 84%, respectively. Local recurrence on CT images was observed in 19% (n = 80) of the RT sites, and the median recurrence time was 3.5 months (range, 1-106 months). In univariate analysis, abnormal laboratory data before RT (platelet count, serum albumin, total bilirubin, lactate dehydrogenase, or serum calcium level), high-risk primary tumor sites (colorectal, esophageal, hepatobiliary/pancreatic, renal/ureter, and non-epithelial cancers), no antineoplastic agents (ATs) administration after RT, and no bone modifying agents (BMAs) administration after RT were significantly unfavorable factors for both survival and LC of RT sites. Sex (male), performance status (≥3), and RT dose (BED10) (<39.0 Gy) were significantly unfavorable factors for only survival, and age (≥70 years) and bone cortex destruction were significantly unfavorable factors for only LC of RT sites. In multivariate analysis, only abnormal laboratory data before RT influenced both unfavorable survival and LC of RT sites. Performance status (≥3), no ATs administration after RT, RT dose (BED10) (<39.0 Gy), and sex (male) were significantly unfavorable factors for survival, and primary tumor sites and BMAs administration after RT were significantly unfavorable factors for LC of RT sites. In conclusion, laboratory data before RT was important factor both prognosis and LC of bone metastases treated with palliative RT. At least in patients with abnormal laboratory data before RT, palliative RT seemed to be focused on the only pain relief.
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Affiliation(s)
- Kenji Makita
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon 791-0295, Ehime, Japan
- Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama 791-0280, Ehime, Japan
- Correspondence: ; Tel.: +81-89-960-5371; Fax: +81-89-960-5375
| | - Yasushi Hamamoto
- Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama 791-0280, Ehime, Japan
| | - Hiromitsu Kanzaki
- Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama 791-0280, Ehime, Japan
| | - Kei Nagasaki
- Department of Radiation Oncology, National Hospital Organization Shikoku Cancer Center, Kou-160, Minami-Umenomoto-Machi, Matsuyama 791-0280, Ehime, Japan
| | - Noriko Takata
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon 791-0295, Ehime, Japan
| | - Shintaro Tsuruoka
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon 791-0295, Ehime, Japan
| | - Kotaro Uwatsu
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon 791-0295, Ehime, Japan
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon 791-0295, Ehime, Japan
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31
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When Patience is a Failing: The Case for Patient Reported Outcomes Adoption. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00091-3. [PMID: 36724856 DOI: 10.1016/j.ijrobp.2023.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 01/30/2023]
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32
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Daugherty EC, Mascia A, Zhang Y, Lee E, Xiao Z, Sertorio M, Woo J, McCann C, Russell K, Levine L, Sharma R, Khuntia D, Bradley J, Simone CB, Perentesis J, Breneman J. FLASH Radiotherapy for the Treatment of Symptomatic Bone Metastases (FAST-01): Protocol for the First Prospective Feasibility Study. JMIR Res Protoc 2023; 12:e41812. [PMID: 36206189 PMCID: PMC9893728 DOI: 10.2196/41812] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/29/2022] [Accepted: 10/04/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In preclinical studies, FLASH therapy, in which radiation delivered at ultrahigh dose rates of ≥40 Gy per second, has been shown to cause less injury to normal tissues than radiotherapy delivered at conventional dose rates. This paper describes the protocol for the first-in-human clinical investigation of proton FLASH therapy. OBJECTIVE FAST-01 is a prospective, single-center trial designed to assess the workflow feasibility, toxicity, and efficacy of FLASH therapy for the treatment of painful bone metastases in the extremities. METHODS Following informed consent, 10 subjects aged ≥18 years with up to 3 painful bone metastases in the extremities (excluding the feet, hands, and wrists) will be enrolled. A treatment field selected from a predefined library of plans with fixed field sizes (from 7.5 cm × 7.5 cm up to 7.5 cm × 20 cm) will be used for treatment. Subjects will receive 8 Gy of radiation in a single fraction-a well-established palliative regimen evaluated in prior investigations using conventional dose rate photon radiotherapy. A FLASH-enabled Varian ProBeam proton therapy unit will be used to deliver treatment to the target volume at a dose rate of ≥40 Gy per second, using the plateau (transmission) portion of the proton beam. After treatment, subjects will be assessed for pain response as well as any adverse effects of FLASH radiation. The primary end points include assessing the workflow feasibility and toxicity of FLASH treatment. The secondary end point is pain response at the treated site(s), as measured by patient-reported pain scores, the use of pain medication, and any flare in bone pain after treatment. The results will be compared to those reported historically for conventional dose rate photon radiotherapy, using the same radiation dose and fractionation. RESULTS FAST-01 opened to enrollment on November 3, 2020. Initial results are expected to be published in 2022. CONCLUSIONS The results of this investigation will contribute to further developing and optimizing the FLASH-enabled ProBeam proton therapy system workflow. The pain response and toxicity data acquired in our study will provide a greater understanding of FLASH treatment effects on tumor responses and normal tissue toxicities, and they will inform future FLASH trial designs. TRIAL REGISTRATION : ClinicalTrials.gov NCT04592887; http://clinicaltrials.gov/ct2/show/NCT04592887. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41812.
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Affiliation(s)
- Emily C Daugherty
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, United States
| | - Anthony Mascia
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, United States
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Yong Zhang
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, United States
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Eunsin Lee
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, United States
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Zhiyan Xiao
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, United States
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Mathieu Sertorio
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, United States
| | - Jennifer Woo
- Varian, A Siemens Healthineers Company, Palo Alto, CA, United States
| | - Claire McCann
- Varian, A Siemens Healthineers Company, Palo Alto, CA, United States
| | - Kenneth Russell
- Varian, A Siemens Healthineers Company, Palo Alto, CA, United States
| | - Lisa Levine
- Varian, A Siemens Healthineers Company, Palo Alto, CA, United States
| | - Ricky Sharma
- Varian, A Siemens Healthineers Company, Palo Alto, CA, United States
| | - Deepak Khuntia
- Varian, A Siemens Healthineers Company, Palo Alto, CA, United States
| | - Jeffrey Bradley
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Charles B Simone
- Department of Radiation Oncology, New York Proton Center, New York, NY, United States
| | - John Perentesis
- Cancer and Blood Disease Institute, Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - John Breneman
- Department of Radiation Oncology, University of Cincinnati, Cincinnati, OH, United States
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33
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Farris JC, Johnson AG, Carriere PP, Patel ZA, Nagatsuka M, Farris MK, Hughes RT. Palliative Appropriateness Criteria: A Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation. J Palliat Med 2023; 26:67-72. [PMID: 35881861 PMCID: PMC9810497 DOI: 10.1089/jpm.2022.0173] [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] [Indexed: 01/13/2023] Open
Abstract
Purpose: To describe a novel metric to aid clinical decision making between shorter versus longer palliative radiotherapy (PRT) regimens using objective patient factors. Materials and Methods: Patients receiving PRT at a single institution between 2014 and 2018 were reviewed. The time between PRT start and finish was calculated and divided by overall survival (in days from start of PRT) to generate the percent of remaining life (PRL). This value was compared across various clinical factors using the Kruskal-Wallis test. Factors identified with a significance level p < 0.01 were included in a novel Palliative Appropriateness Criteria Score (PACS) and were included in an online risk assessment tool to assist clinicians in patient-specific fractionation decisions. Results: Totally 1027 courses of PRT were analyzed. Median age was 64 years; Eastern Cooperative Oncology Group (ECOG) performance status was 3-4 in 22%. Primary malignancies included were lung (38%), breast (13.8%), prostate (9.3%), and other (39%). The indication for PRT was pain (61%), neurological (21%), or other (18%). Palliative regimens included 199 (19.4%) receiving single fraction, 176 (17.1%) receiving 2-5 fractions, and 652 (63.5%) receiving 10 fractions. Median follow-up was 83 days overall and 437 days for patients alive at last follow-up. Factors significantly associated with increased PRL (and included in the PACS) were male gender, ECOG 3-4, lung or "other" primary diagnosis (vs. breast or prostate), PRT indication (neurological dysfunction vs. pain/other), inpatient status, and extraosseous sites treatment. Death within 30 days was significantly associated with high-risk PACS categorization, regardless of fractionation scheme (p < 0.001). Conclusions: The PACS is a novel metric for evaluating the utility of PRT regimens to improve clinical decision making. Single fraction is associated with low PRL. When considering multifraction PRT regimens, the PACS identifies patients who may benefit from shorter courses of PRT and alternatively, low-risk patients for whom a more protracted course is reasonable. Prospective external validation is warranted.
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Affiliation(s)
- Joshua C. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam G. Johnson
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Patrick P. Carriere
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Zachary A. Patel
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Moeko Nagatsuka
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Michael K. Farris
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ryan T. Hughes
- Department of Radiation Oncology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA.,Address correspondence to: Ryan T. Hughes, MD, Department of Radiation Oncology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
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34
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Mascia AE, Daugherty EC, Zhang Y, Lee E, Xiao Z, Sertorio M, Woo J, Backus LR, McDonald JM, McCann C, Russell K, Levine L, Sharma RA, Khuntia D, Bradley JD, Simone CB, Perentesis JP, Breneman JC. Proton FLASH Radiotherapy for the Treatment of Symptomatic Bone Metastases: The FAST-01 Nonrandomized Trial. JAMA Oncol 2023; 9:62-69. [PMID: 36273324 PMCID: PMC9589460 DOI: 10.1001/jamaoncol.2022.5843] [Citation(s) in RCA: 73] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 01/24/2023]
Abstract
Importance To our knowledge, there have been no clinical trials of ultra-high-dose-rate radiotherapy delivered at more than 40 Gy/sec, known as FLASH therapy, nor first-in-human use of proton FLASH. Objectives To assess the clinical workflow feasibility and treatment-related toxic effects of FLASH and pain relief at the treatment sites. Design, Setting, and Participants In the FAST-01 nonrandomized trial, participants treated at Cincinnati Children's/UC Health Proton Therapy Center underwent palliative FLASH radiotherapy to extremity bone metastases. Patients 18 years and older with 1 to 3 painful extremity bone metastases and life expectancies of 2 months or more were eligible. Patients were excluded if they had foot, hand, and wrist metastases; metastases locally treated in the 2 weeks prior; metal implants in the treatment field; known enhanced tissue radiosensitivity; and implanted devices at risk of malfunction with radiotherapy. One of 11 patients who consented was excluded based on eligibility. The end points were evaluated at 3 months posttreatment, and patients were followed up through death or loss to follow-up for toxic effects and pain assessments. Of the 10 included patients, 2 died after the 2-month follow-up but before the 3-month follow-up; 8 participants completed the 3-month evaluation. Data were collected from November 3, 2020, to January 28, 2022, and analyzed from January 28, 2022, to September 1, 2022. Interventions Bone metastases were treated on a FLASH-enabled (≥40 Gy/sec) proton radiotherapy system using a single-transmission proton beam. This is consistent with standard of care using the same prescription (8 Gy in a single fraction) but on a conventional-dose-rate (approximately 0.03 Gy/sec) photon radiotherapy system. Main Outcome and Measures Main outcomes included patient time on the treatment couch, device-related treatment delays, adverse events related to FLASH, patient-reported pain scores, and analgesic use. Results A total of 10 patients (age range, 27-81 years [median age, 63 years]; 5 [50%] male) underwent FLASH radiotherapy at 12 metastatic sites. There were no FLASH-related technical issues or delays. The average (range) time on the treatment couch was 18.9 (11-33) minutes per patient and 15.8 (11-22) minutes per treatment site. Median (range) follow-up was 4.8 (2.3-13.0) months. Adverse events were mild and consistent with conventional radiotherapy. Transient pain flares occurred in 4 of the 12 treated sites (33%). In 8 of the 12 sites (67%) patients reported pain relief, and in 6 of the 12 sites (50%) patients reported a complete response (no pain). Conclusions and Relevance In this nonrandomized trial, clinical workflow metrics, treatment efficacy, and safety data demonstrated that ultra-high-dose-rate proton FLASH radiotherapy was clinically feasible. The treatment efficacy and the profile of adverse events were comparable with those of standard-of-care radiotherapy. These findings support the further exploration of FLASH radiotherapy in patients with cancer. Trial Registration ClinicalTrials.gov Identifier: NCT04592887.
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Affiliation(s)
- Anthony E. Mascia
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Emily C. Daugherty
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Yongbin Zhang
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eunsin Lee
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Zhiyan Xiao
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mathieu Sertorio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Jennifer Woo
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Lori R. Backus
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Julie M. McDonald
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Claire McCann
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Kenneth Russell
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Lisa Levine
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Ricky A. Sharma
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Dee Khuntia
- Varian Medical Systems, Siemens Healthineers, Palo Alto, California
| | - Jeffrey D. Bradley
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Charles B. Simone
- Department of Radiation Oncology, New York Proton Center, New York, New York
| | - John P. Perentesis
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - John C. Breneman
- Cancer and Blood Diseases Institute, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Radiation Oncology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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35
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Takada M, Yoshimura M, Kotake T, Kawaguchi K, Uozumi R, Kataoka M, Kato H, Yoshibayashi H, Suwa H, Tsuji W, Yamashiro H, Suzuki E, Torii M, Yamada Y, Kataoka T, Ishiguro H, Morita S, Toi M. Phase Ib/II study of nivolumab combined with palliative radiation therapy for bone metastasis in patients with HER2-negative metastatic breast cancer. Sci Rep 2022; 12:22397. [PMID: 36575361 PMCID: PMC9794767 DOI: 10.1038/s41598-022-27048-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Radiation therapy (RT) can enhance the abscopal effect of immune checkpoint blockade. This phase I/II study investigated the efficacy and safety of nivolumab plus RT in HER2-negative metastatic breast cancer requiring palliative RT for bone metastases. Cohort A included luminal-like disease, and cohort B included both luminal-like and triple-negative disease refractory to standard systemic therapy. Patients received 8 Gy single fraction RT for bone metastasis on day 0. Nivolumab was administered on day 1 for each 14-day cycle. In cohort A, endocrine therapy was administered. The primary endpoint was the objective response rate (ORR) of the unirradiated lesions. Cohorts A and B consisted of 18 and 10 patients, respectively. The ORR was 11% (90% CI 4-29%) in cohort A and 0% in cohort B. Disease control rates were 39% (90% CI 23-58%) and 0%. Median progression-free survival was 4.1 months (95% CI 2.1-6.1 months) and 2.0 months (95% CI 1.2-3.7 months). One patient in cohort B experienced a grade 3 adverse event. Palliative RT combined with nivolumab was safe and showed modest anti-tumor activity in cohort A. Further investigations to enhance the anti-tumor effect of endocrine therapy combined with RT plus immune checkpoint blockade are warranted.Trial registration number and date of registration UMIN: UMIN000026046, February 8, 2017; ClinicalTrials.gov: NCT03430479, February 13, 2018; Date of the first registration: June 22, 2017.
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Affiliation(s)
- Masahiro Takada
- grid.258799.80000 0004 0372 2033Department of Breast Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Michio Yoshimura
- grid.258799.80000 0004 0372 2033Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kotake
- grid.414973.cDepartment of Medical Oncology, Kansai Electric Power Hospital, Osaka, Japan
| | - Kosuke Kawaguchi
- grid.258799.80000 0004 0372 2033Department of Breast Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Ryuji Uozumi
- grid.258799.80000 0004 0372 2033Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masako Kataoka
- grid.258799.80000 0004 0372 2033Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hironori Kato
- grid.410835.bDepartment of Breast Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Hirofumi Suwa
- grid.413697.e0000 0004 0378 7558Department of Breast Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Wakako Tsuji
- grid.416499.70000 0004 0595 441XDepartment of Breast Surgery, Shiga General Hospital, Moriyama, Japan
| | - Hiroyasu Yamashiro
- grid.416952.d0000 0004 0378 4277Department of Breast Surgery, Tenri Hospital, Tenri, Japan
| | - Eiji Suzuki
- grid.410843.a0000 0004 0466 8016Department of Breast Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masae Torii
- grid.414936.d0000 0004 0418 6412Department of Breast Surgery, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Yosuke Yamada
- grid.411217.00000 0004 0531 2775Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Tatsuki Kataoka
- grid.411790.a0000 0000 9613 6383Department of Pathology, Iwate Medical University, Yahaba, Japan
| | - Hiroshi Ishiguro
- grid.412377.40000 0004 0372 168XBreast Oncology Service, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Satoshi Morita
- grid.258799.80000 0004 0372 2033Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masakazu Toi
- grid.258799.80000 0004 0372 2033Department of Breast Surgery, Kyoto University Graduate School of Medicine, 54 Kawaharacho, Shogoin, Sakyo-Ku, Kyoto, 606-8507 Japan
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125I brachytherapy: a useful treatment to control painful osteoblastic bone metastases. Clin Transl Oncol 2022; 25:1297-1306. [PMID: 36472748 PMCID: PMC10119221 DOI: 10.1007/s12094-022-03025-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
Abstract
Backgrounds
125I brachytherapy is effective in relieving cancer pain due to osteolytic bone metastases. However, fewer studies focused on painful osteoblastic bone metastases (OBMs), we conducted a retrospective study to evaluate the efficacy of 125I brachytherapy for the treatment of painful OBMs.
Methods
From April 2017 to April 2019, clinical data of a total of 65 patients with OBMs who underwent CT/cone beam CT -guided 125I brachytherapy were collected and analyzed. The primary study endpoints were technical success, relief of pain (RoP), and quality of life (QoL). The secondary study endpoints were treatment-related complications, local tumor control (LCR), and overall survival (OS). The logistic regression analysis was performed to predict RoP.
Results
Technical success rate was 100%. Visual analog scale scores and daily morphine consumption continuously decreased significantly at 2 weeks, 6 weeks, and 10 weeks (all P < 0.05). The RoP at 6 weeks was 84.62%. QoL presented improvement at 6 and 10 weeks. Only minor complications occurred in 12 patients (18.46%). LCR was 93.85% at 10 weeks. The OS was 29.80 months. Two factors were significantly associated with the RoP: max diameter (MD, < 3 cm vs. ≥ 3 cm, P = 0.019) and serum levels of bone alkaline phosphatase (B-ALP, ≥ 100 U/L vs. < 100 U/L, P = 0.016).
Conclusions
125I brachytherapy is an effective treatment in relieving painful OBMs and improving patients’ QoL.
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Dose-escalated radiotherapy with simultaneous integrated boost for bone metastases in selected patients with assumed favourable prognosis. Radiol Oncol 2022; 56:515-524. [PMID: 36503710 PMCID: PMC9784373 DOI: 10.2478/raon-2022-0053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/11/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Stereotactic body radiotherapy (SBRT) concepts for dose escalation are increasingly used for bone metastases in patients with oligometastatic or oligoprogressive disease. For metastases that are not suitable for SBRT-regimens, a treatment with 30/40 Gy with simultaneous integrated boost (SIB) in 10 fractions represents a possible regimen. The aim of this study was to investigate the feasibility of this concept and the acute and subacute toxicities. PATIENTS AND METHODS Clinical records for dose-escalated radiotherapy of all consecutive patients treated with this regimen were evaluated retrospectively (24 patients with 28 target volumes for oncologic outcomes and 25 patients with 29 target volumes for treatment feasibility and dose parameters analysis). Analysis of radiotherapy plans included size of target volumes and dosimetric parameter for target volumes and organs at risk (OAR). Acute and subacute toxicities were evaluated according to Common Terminology Criteria for Adverse Events (CTCAE) V4.0. RESULTS The most common localization was the spine (71.4%). The most common histology was prostate cancer (45.8%). Oligometastatic or oligoprogressive disease was the indication for dose-escalated radiotherapy in 19/24 patients (79.2%). Treatment was feasible with all patients completing radiotherapy. Acute toxicity grade 1 was documented in 36.0% of the patients. During follow up, one patient underwent surgery due to bone instability. The 1-year local control and patient-related progression-free survival (PFS) were 90.0 ± 6.7% and 33.3 ± 11.6%, respectively. CONCLUSIONS Dose-escalated hypofractionated radiotherapy with simultaneous integrated boost for bone metastases resulted in good local control with limited acute toxicities. Only one patient required surgical intervention. The regimen represents an alternative to SBRT in selected patients.
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Muacevic A, Adler JR, Razavian NB, Farris JC, Hughes RT. Skeletal-Related Events After Surgery With or Without Radiotherapy for Bone Metastases to Weight-Bearing Bones. Cureus 2022; 14:e32778. [PMID: 36686116 PMCID: PMC9854333 DOI: 10.7759/cureus.32778] [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] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction In patients with metastatic disease involving weight-bearing bones, postoperative radiotherapy (PORT) is commonly administered following surgical stabilization of an impending or confirmed pathologic fracture to reduce the risk of a seeded local recurrence. The goal was to re-evaluate the beneficial effect of PORT in a modern cohort of patients and determine any potential clinical predictors of skeletal-related events (SREs) which were defined as a pathologic fracture or the necessity for radiation or surgery to the affected bone. Methods Consecutive patients undergoing surgical stabilization of metastatic disease to weight-bearing bones of the extremities between 2012 and 2019 were reviewed. Patient, disease, and treatment factors were abstracted. The cumulative incidence of SREs was determined using competing risks methodology; overall survival (OS) was estimated using the Kaplan-Meier method. Results A total of 82 patients were identified, 74% of whom had undergone intramedullary nail fixation and 26% internal fixation or replacement. The femur was the most commonly involved bone (94%). A majority (78%) had an Eastern Cooperative Oncology Group (ECOG) performance status of 1-2. Bone-strengthening agents were given to 38% and PORT to 54%. The median PORT dose was 30 Gy in 10 fractions and the median percent coverage of surgical hardware was 100% (range, 25-100). SREs occurred in 10 of 82 patients. There were no differences between no RT and RT groups for the two-year cumulative incidence of SREs (8.2% vs 11.5%, p=0.59) or two-year cumulative incidence of local failure (10.8% vs 4.6%, p=0.53). The only identified predictors of SREs were the use of bone-strengthening agents (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.05-1.06, p=0.06) and malnutrition (HR 3.69, 95% CI 0.91-14.93, p=0.07). For patients treated with PORT, a biologically effective dose or percent coverage of surgical hardware was not associated with SREs. Conclusion In this series, the addition of PORT following surgery for metastatic disease involving weight-bearing bones does not significantly affect the rate of SREs. The use of bone-strengthening agents appears protective, and malnourished patients appear particularly at high risk for future SRE.
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Wang Z, Li L, Yang X, Teng H, Wu X, Chen Z, Wang Z, Chen G. Efficacy and safety of stereotactic body radiotherapy for painful bone metastases: Evidence from randomized controlled trials. Front Oncol 2022; 12:979201. [PMID: 36338685 PMCID: PMC9627033 DOI: 10.3389/fonc.2022.979201] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/28/2022] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Pain relief is one of the main objectives of radiotherapy for cancer patients with bone metastases. Stereotactic body radiotherapy (SBRT) enables precise delivery of a higher dosage to the target area. Several trials have reported comparisons between SBRT and conventional radiotherapy (cRT) in patients with painful bone metastasis. However, the results of those investigations were inconsistent, and no systematic review or meta-analysis has been done till now. METHODS We systematically searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov up to May 1, 2022 for relevant studies. Patients with painful bone metastasis who received SBRT or cRT were included. The primary outcome was the patients' pain response rate at three months. The secondary outcomes included the rate of pain responders at one month and six months, oral morphine equivalent dose (OMED) use, and any adverse events. STATA software 12.0 was used for the statistical analysis. RESULTS We collected 533 patients' data from 4 randomized controlled trials (RCTs), there was a significant difference of pain response rate at 3 months between two groups (RR = 1.41, 95% CI: 1.12-1.77, I2 = 0.0%, P = 0.003). However, no significant difference was found in pain response rate at 1 month (RR = 1.19, 95% CI: 0.91-1.54, I2 = 31.5%, P = 0.201) and 6 months (RR = 1.25, 95% CI: 0.93-1.69, I2 = 0.0%, P = 0.140). OMED consumption was not significantly different in patients treated with SBRT compared with control group (WMD = -1.11, 95% CI: -17.51-15.28, I2 = 0.0%, P = 0.894). For safety outcome, no statistical difference was found between SBRT and cRT (RR = 0.72, 95% CI: 0.46-1.14, I2=20.1%, P = 0.162). CONCLUSION This study shows that for painful bone metastases, patients with SBRT experienced better pain relief 3 months after radiation than patients with cRT, and SBRT did not increase the incidence of adverse events. SYSTEMATIC REVIEW REGISTRATION https://inplasy.com/inplasy-2022-6-0099/, identifier INPLASY202260099.
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Affiliation(s)
- Zilan Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Longyuan Li
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xingyu Yang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Haiying Teng
- Department of Suzhou Medical College, Soochow University, Suzhou, China
| | - Xiaoxiao Wu
- Department of Suzhou Medical College, Soochow University, Suzhou, China
| | - Zhouqing Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Gang Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, China
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Brundage MD, Crossnohere NL, O’Donnell J, Cruz Rivera S, Wilson R, Wu AW, Moher D, Kyte D, Reeve BB, Gilbert A, Chen RC, Calvert MJ, Snyder C. Listening to the Patient Voice Adds Value to Cancer Clinical Trials. J Natl Cancer Inst 2022; 114:1323-1332. [PMID: 35900186 PMCID: PMC9552306 DOI: 10.1093/jnci/djac128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/11/2022] [Accepted: 06/02/2022] [Indexed: 11/16/2022] Open
Abstract
Randomized clinical trials are critical for evaluating the safety and efficacy of interventions in oncology and informing regulatory decisions, practice guidelines, and health policy. Patient-reported outcomes (PROs) are increasingly used in randomized trials to reflect the impact of receiving cancer therapies from the patient perspective and can inform evaluations of interventions by providing evidence that cannot be obtained or deduced from clinicians' reports or from other biomedical measures. This commentary focuses on how PROs add value to clinical trials by representing the patient voice. We employed 2 previously published descriptive frameworks (addressing how PROs are used in clinical trials and how PROs have an impact, respectively) and selected 9 clinical trial publications that illustrate the value of PROs according to the framework categories. These include 3 trials where PROs were a primary trial endpoint, 3 trials where PROs as secondary endpoints supported the primary endpoint, and 3 trials where PROs as secondary endpoints contrast the primary endpoint findings in clinically important ways. The 9 examples illustrate that PROs add valuable data to the care and treatment context by informing future patients about how they may feel and function on different treatments and by providing clinicians with evidence to support changes to clinical practice and shared decision making. Beyond the patient and clinician, PROs can enable administrators to consider the cost-effectiveness of implementing new interventions and contribute vital information to policy makers, health technology assessors, and regulators. These examples provide a strong case for the wider implementation of PROs in cancer trials.
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Affiliation(s)
- Michael D Brundage
- Queen’s University Cancer Research Institute, Cancer Care and Epidemiology, Kingston, ON, Canada
| | - Norah L Crossnohere
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jennifer O’Donnell
- Queen’s University Cancer Research Institute, Cancer Care and Epidemiology, Kingston, ON, Canada
| | - Samantha Cruz Rivera
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- DEMAND (Data-Enabled Medical Technologies and Devices) Hub, University of Birmingham, Birmingham, UK
| | - Roger Wilson
- NCRI Consumer Forum National Cancer Research Institute, London, UK
| | - Albert W Wu
- Johns Hopkins Bloomberg School of Public Health and School of Medicine, Baltimore, MD, USA
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Derek Kyte
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- School of Allied Health and Community, University of Worcester, Worcester, UK
| | - Bryce B Reeve
- Center for Health Measurement, Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James’s, University of Leeds, Leeds, UK
| | - Ronald C Chen
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Melanie J Calvert
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Birmingham Health Partners Centre for Regulatory Science and Innovation, University of Birmingham, Birmingham, UK
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre, Birmingham, UK
- NIHR Applied Research Collaboration West Midlands, Coventry, UK
- NIHR Surgical Reconstruction and Microbiology Centre, University of Birmingham, Birmingham, UK
| | - Claire Snyder
- Johns Hopkins Bloomberg School of Public Health and School of Medicine, Baltimore, MD, USA
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YILMAZ U, YAPRAK G, IŞIK N. Evaluation of treatment results of stereotactic body radiotherapy for spinal metastases: A single center experience. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1134145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aim: To assess oncological outcomes and adverse events of patients receiving single or multi-fraction stereotactic body radiotherapy (SBRT) for spine metastases.
Material and Method: Patients with any pathologically proven solid tumor histology who had SBRT to the spine for recurrent or metastatic disease between the years 2010 and 2021 at our department were identified from institutional database. Patient, tumor and treatment characteristics, and follow-up medical records were retrospectively reviewed. Local control (LC) and overall survival (OS) rates were calculated, and adverse events were evaluated.
Results: A total of 47 patients were treated to 50 spine metastases. Median age was 53 years for all patients. Histologies included breast cancer (45%), non-small cell lung cancer (NSCLC; 21%), prostate cancer (15%) and other types (19%). Median follow-up was 16 months for all patients. Of 47 patients, six (13%) developed local failure and 15 (32%) died without local failure. One and two-year actuarial LC rates were 90.1% and 83.6%, respectively. One and two-year OS rates were 75.1% and 62.7%, respectively. Twenty-two (47%) patients had pain before SBRT. Fifteen (68%) of them had complete or partial pain response at 3 months after SBRT. Vertebral compression fracture, which was grade 1 in severity according to the Common Terminology Criteria for Adverse Events (CTCAE [v.4.03]), was observed in only one (2%) patient and it occurred 46 months after SBRT. No cases of treatment-related radiation myelopathy or any≥grade 3 RT induced acute or late toxicities occurred.
Conclusion: This study supports that SBRT to the spine results in high LC without any significant toxicity. The results of ongoing phase 3 trials will highlight whether this high LC benefit reflects to survival in oligometastatic disease.
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Affiliation(s)
- Uğur YILMAZ
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL KARTAL DR. LÜTFİ KIRDAR ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYASYON ONKOLOJİSİ ANABİLİM DALI
| | - Gökhan YAPRAK
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL KARTAL DR. LÜTFİ KIRDAR ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYASYON ONKOLOJİSİ ANABİLİM DALI
| | - Naciye IŞIK
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL KARTAL DR. LÜTFİ KIRDAR ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYASYON ONKOLOJİSİ ANABİLİM DALI
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Rühle A, Nya Yompang VA, Spohn SKB, Stoian R, Zamboglou C, Gkika E, Grosu AL, Nicolay NH, Sprave T. Palliative radiotherapy of bone metastases in octogenarians: How do the oldest olds respond? Results from a tertiary cancer center with 288 treated patients. Radiat Oncol 2022; 17:153. [PMID: 36071522 PMCID: PMC9450461 DOI: 10.1186/s13014-022-02122-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accompanied by the demographic change, the number of octogenarian cancer patients with bone metastases will increase in the future. Palliative radiotherapy constitutes an effective analgesic treatment; however, as pain perception and bone metabolism change with increasing age, the analgesic efficacy of radiotherapy may be altered in elderly patients. We therefore investigated the treatment outcomes of palliative radiotherapy for bone metastases in octogenarians. METHODS Patients between 80 and 89 years undergoing radiotherapy for bone metastases between 2009 and 2019 at a tertiary cancer center were analyzed for patterns-of-care, pain response and overall survival (OS). Logistic regression analyses were carried out to examine parameters associated with pain response, and Cox analyses were conducted to reveal prognostic parameters for OS. RESULTS A total of 288 patients with 516 irradiated lesions were included in the analysis. The majority (n = 249, 86%) completed all courses of radiotherapy. Radiotherapy led to pain reduction in 176 patients (61%) at the end of treatment. Complete pain relief at the first follow-up was achieved in 84 patients (29%). Bisphosphonate administration was significantly associated with higher rates of pain response at the first follow-up (p < 0.05). Median OS amounted to 9 months, and 1-year, 2-year and 3-year OS were 43%, 28% and 17%. In the multivariate analysis, ECOG (p < 0.001), Mizumoto score (p < 0.01) and Spinal Instability Neoplastic Score (SINS) (p < 0.001) were independent prognosticators for OS. CONCLUSION Palliative radiotherapy for bone metastases constitutes a feasible and effective analgesic treatment in octogenarian patients. ECOG, Mizumoto score and SINS are prognosic variables for survival and may aid treatment decisions regarding radiotherapy fractionation in this patient group. Single-fraction radiotherapy with 8 Gy should be applied for patients with uncomplicated bone metastases and poor prognosis. Prospective trials focusing on quality of life of these very old cancer patients with bone metastases are warranted to reveal the optimal radiotherapeutic management for this vulnerable population.
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Affiliation(s)
- Alexander Rühle
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Verlaine Ange Nya Yompang
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Simon K B Spohn
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Raluca Stoian
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany.,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University of Freiburg - Medical Center, Robert-Koch-Str. 3, 79106, Freiburg, Germany. .,German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Fabian A, Domschikowski J, Letsch A, Schmalz C, Freitag-Wolf S, Dunst J, Krug D. Use and Reporting of Patient-Reported Outcomes in Trials of Palliative Radiotherapy: A Systematic Review. JAMA Netw Open 2022; 5:e2231930. [PMID: 36136335 PMCID: PMC9500555 DOI: 10.1001/jamanetworkopen.2022.31930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE Approximately 50% of all patients with cancer have an indication for radiotherapy, and approximately 50% of radiotherapy is delivered with palliative intent, with the aim of alleviating symptoms. Symptoms are best assessed by patient-reported outcomes (PROs), yet their reliable interpretation requires adequate reporting in publications. OBJECTIVE To investigate the use and reporting of PROs in clinical trials of palliative radiotherapy. EVIDENCE REVIEW This preregistered systematic review searched PubMed/Medline, EMBASE, and the Cochrane Center Register of Controlled Trials for clinical trials of palliative radiotherapy published from 1990 to 2020. Key eligibility criteria were palliative setting, palliative radiotherapy as treatment modality, and clinical trial design (per National Institutes of Health definition). Two authors independently assessed eligibility. Trial characteristics were extracted and standard of PRO reporting was assessed in adherence to the Consolidated Standards of Reporting Trials (CONSORT) PRO extension. The association of the year of publication with the use of PROs was assessed by logistic regression. Factors associated with higher CONSORT-PRO adherence were analyzed by multiple regression. This study is reported following the PRISMA guidelines. FINDINGS Among 7377 records screened, 225 published clinical trials representing 24 281 patients were eligible. Of these, 45 trials (20%) used a PRO as a primary end point and 71 trials (31%) used a PRO as a secondary end point. The most prevalent PRO measures were the Numeric Rating Scale/Visual Analogue Scale (38 trials), European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire C30 (32 trials), and trial-specific unvalidated measures (25 trials). A more recent year of publication was significantly associated with a higher chance of PROs as a secondary end point (odds ratio [OR], 1.04 [95% CI, 1.00-1.07]; P = .03) but not as primary end point. Adherence to CONSORT-PRO was poor or moderate for most items. Mean (SD) adherence to the extension adherence score was 46.2% (19.6%) for trials with PROs as primary end point and 31.8% (19.8%) for trials with PROs as a secondary end point. PROs as a primary end point (regression coefficient, 9.755 [95% CI, 2.270-17.240]; P = .01), brachytherapy as radiotherapy modality (regression coefficient, 16.795 [95% CI, 5.840-27.751]; P = .003), and larger sample size (regression coefficient, 0.028 [95% CI, 0.006-0.049]; P = .01) were significantly associated with better PRO reporting per extension adherence score. CONCLUSIONS AND RELEVANCE In this systematic review of palliative radiotherapy trials, the use and reporting of PROs had room for improvement for future trials, preferably with PROs as a primary end point.
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Affiliation(s)
- Alexander Fabian
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Justus Domschikowski
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Anne Letsch
- Department of Haematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Claudia Schmalz
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and Statistics, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Juergen Dunst
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
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Anderson DE, Groff MW, Flood TF, Allaire BT, Davis RB, Stadelmann MA, Zysset PK, Alkalay RN. Evaluation of Load-To-Strength Ratios in Metastatic Vertebrae and Comparison With Age- and Sex-Matched Healthy Individuals. Front Bioeng Biotechnol 2022; 10:866970. [PMID: 35992350 PMCID: PMC9388746 DOI: 10.3389/fbioe.2022.866970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
Vertebrae containing osteolytic and osteosclerotic bone metastases undergo pathologic vertebral fracture (PVF) when the lesioned vertebrae fail to carry daily loads. We hypothesize that task-specific spinal loading patterns amplify the risk of PVF, with a higher degree of risk in osteolytic than in osteosclerotic vertebrae. To test this hypothesis, we obtained clinical CT images of 11 cadaveric spines with bone metastases, estimated the individual vertebral strength from the CT data, and created spine-specific musculoskeletal models from the CT data. We established a musculoskeletal model for each spine to compute vertebral loading for natural standing, natural standing + weights, forward flexion + weights, and lateral bending + weights and derived the individual vertebral load-to-strength ratio (LSR). For each activity, we compared the metastatic spines' predicted LSRs with the normative LSRs generated from a population-based sample of 250 men and women of comparable ages. Bone metastases classification significantly affected the CT-estimated vertebral strength (Kruskal-Wallis, p < 0.0001). Post-test analysis showed that the estimated vertebral strength of osteosclerotic and mixed metastases vertebrae was significantly higher than that of osteolytic vertebrae (p = 0.0016 and p = 0.0003) or vertebrae without radiographic evidence of bone metastasis (p = 0.0010 and p = 0.0003). Compared with the median (50%) LSRs of the normative dataset, osteolytic vertebrae had higher median (50%) LSRs under natural standing (p = 0.0375), natural standing + weights (p = 0.0118), and lateral bending + weights (p = 0.0111). Surprisingly, vertebrae showing minimal radiographic evidence of bone metastasis presented significantly higher median (50%) LSRs under natural standing (p < 0.0001) and lateral bending + weights (p = 0.0009) than the normative dataset. Osteosclerotic vertebrae had lower median (50%) LSRs under natural standing (p < 0.0001), natural standing + weights (p = 0.0005), forward flexion + weights (p < 0.0001), and lateral bending + weights (p = 0.0002), a trend shared by vertebrae with mixed lesions. This study is the first to apply musculoskeletal modeling to estimate individual vertebral loading in pathologic spines and highlights the role of task-specific loading in augmenting PVF risk associated with specific bone metastatic types. Our finding of high LSRs in vertebrae without radiologically observed bone metastasis highlights that patients with metastatic spine disease could be at an increased risk of vertebral fractures even at levels where lesions have not been identified radiologically.
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Affiliation(s)
- Dennis E. Anderson
- Department of Orthopedic Surgery, Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Michael W. Groff
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, United States
| | - Thomas F. Flood
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Brett T. Allaire
- Department of Orthopedic Surgery, Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Roger B. Davis
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Marc A. Stadelmann
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Philippe K. Zysset
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Ron N. Alkalay
- Department of Orthopedic Surgery, Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
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The 100 most cited papers on bone metastasis: A bibliometric analysis. J Bone Oncol 2022; 35:100443. [PMID: 35815184 PMCID: PMC9263529 DOI: 10.1016/j.jbo.2022.100443] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 06/26/2022] [Accepted: 06/26/2022] [Indexed: 12/20/2022] Open
Abstract
Citations per article in the most 100 top cited articles ranged from 357 to 2167. The leading country was USA, Canada, and United Kingdom. Clinical management of bone metastasis from different malignancy origins. Intense collaborative activity between countries and institutions was obvious between the selected papers.
Background Over the past few decades, a vast number of articles focused on bone metastasis have been published. Bibliometric analysis is helpful to determine the qualities and characteristics and to reveal the influential articles in this field. Methods All the databases in Web of Science were utilized to identify articles published from 1961 to 2020. The top 100 most cited articles on bone metastases were involved for degree centrality analysis and analyses on publication time and citations, journals, authors, geographical distribution, research institutions, and research keywords. Results The selected articles were published mainly from 1986 to 2015. The 100 most cited articles were selected from a total of 67,451 citations out of 90,502 publications with a density of 50.239 citations/year. Citations per article ranged from 357 to 2167. The leading country was USA, followed by Canada and United Kingdom. The most frequently studied themes were clinical management of bone metastasis from different malignancy origins. A co-authorship analysis revealed an intense collaborative activity between countries and institutions. Conclusions This study identified the top 100 most cited articles on bone metastasis. Publication time, area, and theme distribution were thoroughly analyzed. The present study highlighted some of the most influential contributions to the field. Clinical and academic communities have shown a sustained interest in the management of bone metastasis.
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Stereotactic Body Radiation Therapy versus Conventional External Beam Radiation Therapy for Painful Bone Metastases: A Systematic Review and Meta-analysis of Randomized Trials. Crit Rev Oncol Hematol 2022; 178:103775. [PMID: 35917886 DOI: 10.1016/j.critrevonc.2022.103775] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/29/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To compare the efficacy and safety of stereotactic body radiation therapy (SBRT) and conventional external beam radiation therapy (cEBRT) in patients with previously unirradiated painful bone metastases (BM). METHODS We searched biomedical databases for eligible randomized trials (RCTs). The outcomes of interest were pain response, local progression, overall survival (OS) and adverse events. We used established tools to assess the quality of the individual trials and certainty of the pooled evidence. We performed meta-analyses using random effects models. RESULTS Six RCTs were identified. SBRT improved complete pain response rates at 3 months (OR, 3.38; 95% CI, 1.88-6.07; high certainty), reduced local progression rates (OR, 0.19; 95% CI, 0.06-0.62; high certainty) and increase pain flare rates. There were no differences for other outcomes. CONCLUSION Among patients with previously unirradiated painful BM, SBRT significantly improved complete pain response rates at 3 months, delayed local progression and increase pain flare rates.
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Castration-resistant prostate cancer with bone metastases: toward the best therapeutic choice. MEDICAL ONCOLOGY (NORTHWOOD, LONDON, ENGLAND) 2022; 39:145. [PMID: 35834026 DOI: 10.1007/s12032-022-01739-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 04/22/2022] [Indexed: 10/17/2022]
Abstract
The treatment landscape for metastatic castration-resistant prostate cancer has evolved extremely in recent years and several drug classes are now available. Nonetheless, the lack of validated predictive biomarkers makes therapeutic choice and the best sequential approach difficult. The location of the metastatic site could be a valid criterion for choosing among the treatment options available. Although bone remains the most frequent metastatic site and a possible target for many drugs, recent data suggest a profound shift in the disease spectrum with visceral metastases increasing incidence. This review describes the presently available and ongoing therapies for patients with CRPC and bone metastases, focusing on the role of bone metastases as a possible driver for selecting therapies in these patients.
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ESTRO ACROP guidelines for external beam radiotherapy of patients with complicated bone metastases. Radiother Oncol 2022; 173:240-253. [DOI: 10.1016/j.radonc.2022.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 05/31/2022] [Accepted: 06/01/2022] [Indexed: 12/19/2022]
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Henzen D, Schmidhalter D, Guyer G, Stenger-Weisser A, Ermiş E, Poel R, Deml MC, Fix MK, Manser P, Aebersold DM, Hemmatazad H. Feasibility of postoperative spine stereotactic body radiation therapy in proximity of carbon and titanium hybrid implants using a robotic radiotherapy device. Radiat Oncol 2022; 17:94. [PMID: 35549961 PMCID: PMC9097088 DOI: 10.1186/s13014-022-02058-7] [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: 01/30/2022] [Accepted: 04/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background and purpose To assess the feasibility of postoperative stereotactic body radiation therapy (SBRT) for patients with hybrid implants consisting of carbon fiber reinforced polyetheretherketone and titanium (CFP-T) using CyberKnife. Materials and methods All essential steps within a radiation therapy (RT) workflow were evaluated. First, the contouring process of target volumes and organs at risk (OAR) was done for patients with CFP-T implants. Second, after RT-planning, the accuracy of the calculated dose distributions was tested in a slab phantom and an anthropomorphic phantom using film dosimetry. As a third step, the accuracy of the mandatory image guided radiation therapy (IGRT) including automatic matching was assessed using the anthropomorphic phantom. For this goal, a standard quality assurance (QA) test was modified to carry out its IGRT part in presence of CFP-T implants. Results Using CFP-T implants, target volumes could precisely delineated. There was no need for compromising the contours to overcome artifact obstacles. Differences between measured and calculated dose values were below 11% for the slab phantom, and at least 95% of the voxels were within 5% dose difference. The comparisons for the anthropomorphic phantom showed a gamma-passing rate (5%, 1 mm) of at least 97%. Additionally the test results with and without CFP-T implants were comparable. No issues concerning the IGRT were detected. The modified machine QA test resulted in a targeting error of 0.71 mm, which corresponds to the results of the unmodified standard tests. Conclusion Dose calculation and delivery of postoperative spine SBRT is feasible in proximity of CFP-T implants using a CyberKnife system.
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Affiliation(s)
- Dominik Henzen
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Schmidhalter
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gian Guyer
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Stenger-Weisser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ekin Ermiş
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert Poel
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Caspar Deml
- Department of Orthopedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Karl Fix
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter Manser
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Matthias Aebersold
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hossein Hemmatazad
- Division of Medical Radiation Physics and Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Singh R, Valluri A, Jenkins J, Davis J, Vargo JA, Sharma S. Stereotactic Body Radiation Therapy (SBRT) for Spinal Metastases: Real-world Outcomes From an International Multi-institutional SBRT Registry. Am J Clin Oncol 2022; 45:196-201. [PMID: 35393978 DOI: 10.1097/coc.0000000000000909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare clinical outcomes following single fraction versus fractionated stereotactic body radiotherapy (SBRT) for spinal metastases. MATERIALS AND METHODS A multi-institutional registry was queried for patients with spinal metastases treated with single-fraction or fractionated SBRT. Potential predictive factors of local control (LC) and overall survival were evaluated. Pretreatment and posttreatment Visual Analog Scale scores were analyzed to examine initial and durable pain responses and complete response (CR) rates. Logistic regression was utilized to assess potential correlations between pain response, biologically effective dose (BED), and fractionation. RESULTS Four hundred sixty-six patients with 514 lesions treated with SBRT were identified; 209 and 104 lesions had information on LC and pain, respectively. The median pain score of patients with symptoms was 6 (range: 3 to 10). The median follow-up was 8.9 months (range: 0.4 to 125.5 mo). Utilizing Karnofsky Performance Score, age, and primary site (lung and/or nonbreast), 1-year overall survival rates were 76.1%, 59.1%, 54.9%, 37.2%, and 23.5% for patients with 0 to 4 of these factors, respectively (P<0.0001). One- and 2-year LC rates were 79.9% and 73.6%, respectively. Eighty-six patients (82.7%) had an initial pain response with a median decline of 3.5 and a CR rate of 47.1%. Sixty-five patients (62.5%) had a durable pain response with a median decline of 2 and a CR rate of 20.2%. Higher initial CR rates were observed with BED10 ≥51 Gy10 (58.7% vs. 37.9%; P=0.04). CONCLUSIONS Following SBRT, encouraging palliative responses with >80% and 60% of patients having initial and durable pain responses, respectively. Dose escalation may result in improved initial CR rates. Performance status, age, and primary histology are factors to consider in the absence of pain.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA
| | | | | | | | - John A Vargo
- Department of Radiation Oncology, University of Pittsburgh Hillman Cancer Center, Pittsburgh, PA
| | - Sanjeev Sharma
- Department of Radiation Oncology, St. Mary's Medical Center, Huntington, WV
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